A Quality Improvement Project: ANP in Saudi Primary Care Settings

This quality improvement project investigates the introduction of the Advanced Nurse Practitioner (ANP) role within a primary care setting in the Kingdom of Saudi Arabia (KSA). The project aims to evaluate the impact of ANPs on patient satisfaction and waiting times, addressing challenges within the KSA healthcare system, such as increasing demand, leadership issues, and the rise of chronic diseases. The project reviews the existing literature, highlighting the potential benefits of ANPs in enhancing patient safety, improving care, and reducing healthcare costs. The study emphasizes the need for a standardized education system and clearly defined roles for ANPs to optimize their integration into the clinical environment, and the study also identifies the challenges faced by ANPs, including limited autonomy and under-representation, and proposes potential solutions for improving ANP practices in healthcare. The project's objectives include measuring the impact of the ANP introduction and answering the 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?

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

across Northern England revealed that the availed information about GPs, PNs, and APNs to
patients was incomplete and, at times, inaccurate across most of the websites. For instance
the study reported that there was a problem in directing and representing the patients through
the website towards the suitable professional that was supposed to address their problem.
Thus this shows that the ANPs are under-represented due to the scant information that is
available. This shows that both other professionals and patients do not fully understand the
role that these professionals can play in clinical (Anderson, Adamson, & Birks, 2018).
Bergman et al. (2013) also noted that ANP functions are mostly unknown and that ANPs
have limited autonomy, such as being restricted from prescribing medications. Twin et al.
(2004) also stressed the need for independence among individual ANPs based on research
findings drawn from Hong Kong in efforts to facilitate their development in the healthcare
settings.
Additionally, there are potential issues to take into consideration to address the
various knowledge gaps identified in the literature. For instance, findings from Europe by
researchers such as Bergman et al. (2013) and Carnwell and Daly (2003) may be difficult to
replicate in KSA because of the methodological limitations. Twin et al. (2004) noted that
different healthcare settings and geographical regions have various determinants that inform
the way clinical models are applied. For example, in Europe and Asia there are different
cultural factors that influence healthcare needs which influence the approach to care.
According to Duke (2012) these variations inform the role of geographical and demographic
factors in healthcare which create gaps in implementation of clinical practices which also
affect the role of ANPs in healthcare settings.
In summation, ANPs play an essential role in service delivery, quality of care,
broadening patient choice, and accessibility. However, the limited nature of research shows
that the field is still emerging which is seen in the lack of adequate research that can lead to

the recognition of ANPs in clinical settings. This is the reason why healthcare leaders and
managers need to continuously support the ANPs in developing their profession and giving
them an environment where they can practice based on their skills.
3.0 Framework
The purpose of this QI project is to show evidence of improved patient care and
outcomes by introducing the ANP role to a primary care setting in KSA. Primary care at
hospitals in KSA is facing a potential crisis due to a shortage in the number of physicians
providing safe, affordable, and quality healthcare (Oliver, 2017). Due to the aging population
and increased health insurance coverage against a dropping number of general practitioners.
The lowering shortage of physicians in the healthcare settings shows that there is need for
ANPs to be utilised within these settings. However, the lack of implementation due to poor
policies and regulations means that the ANPs are not fully engaged but rather mostly exist
like other nurses. In a scoping review Torrens et al. (2019) highlighted the barriers that ANPs
in primary care settings face in the course of duty. From the review, it was reported that there
are disagreements over the level of autonomy that the ANPs are supposed to have.
The project will use the knowledge to action framework (KTA) to express how
knowledge should be used to initiate actions for ANPs (Graham et al., 2006). Planned action
theory will be applied in reviewing the change process. The theories applicable in this
research are interdisciplinary and primarily based on nursing that were developed some
decades ago (Graham and Tetroe, 2007). The KTA framework comprises two distinct but
related in addressing ANPs impact on primary healthcare settings. Each component of the
process involves the use of several phases that overlap to represent the role that nurse play in
healthcare settings which is based on working with other professionals. The knowledge phase
increases nurse efficiency and role through creating an impact on the action phase. The action
cycle outline the processes and represents the ANP activities that are based on the knowledge

and the skills that they have in the field of practice. In nursing, knowledge is applicable in
practical settings where the ANP faces different barriers and challenges in clinical settings
which are tailored with the knowledge that the ANP has in dealing with the issues that affect
the clinical environment to meet the needs of the people that they serve and determining how
they will benefit from the process (Appendix A).
4.0 Methodology
Knowledge To Action (KTA) framework was chosen to guide the project methodology since
it is important in identifying the challenges that arise during the translation of scientific
evidence into practice, and that is by preparing an individual to deal with different complex
factors that conflict with the successful (Graham et al., 2006). The KTA cycle has two
sections that are divided into phases. The knowledge section is defined as the tube for
regarding available knowledge to other phases. The knowledge created after research is used
to develop the evidence that is sued to form guidelines. The actin section on the other hand
involves activities where knowledge is applied through linking the phases to together to
identify the problem for evaluating the outcomes of the situation and ensuring sustainability.
In this project, the evidence-based framework is used to introduce the APNs role into the
KSA system where the ANPs have not been fully recognised as playing an important role in
meeting the needs of the clinical settings. This means that the ANP are introduced with the
major role of improving the healthcare infrastructure through the level of knowledge that they
have which is different and more advanced as outlined below:
Phase 1: Problem Identification
The primary care clinic covers a total population of about 800 people a day. Family
medicine clinics have admit around 40 patients per day with staff located at different
locations with different roles.
Patient waiting time

The patient waiting time is not defined since the patients only know that they are
supposed to see a doctor but are not sure of the exact waiting time. In KSA, the average
waiting is between 1 to 2 hours. Alarcon-Ruiz et al. (2019) suggests that according to
research the waiting time is not supposed to be more than 30 minutes and if it exceeds this
time then there is a high likelihood that the patient will not be satisfied with the service that
will be offered.
According to Kujala et al. (2006) long waiting time is a common scenario in most
clinical situations due to the proportional patient practitioner ratios. The factors that lead to
waiting time include aging equipment, and attractiveness of the waiting area. Waiting time
affects patients in their adverse utilization of health services which leads to the unwillingness
of the patient to return to the facility which affects the continuity of care. Thus reducing the
waiting time can be important in increasing the desire to continue receiving care at the same
health-care facility.
Patient satisfaction
“I wished I could be anywhere else better than this horrible place and treated by
anyone else” (personal communication from patient to author, 2018). This is a quote by one
patient showing dissatisfaction of health care provided in the corridor. Patient satisfaction is
considered as an important element when measuring healthcare outcomes and the quality of
the care administered. Furthermore, most health authorities worldwide have focussed on
responding to the needs of clients through developing quality improvements in health
services.
The focus of the study is to review patient satisfaction and long waiting time. An
introducing ANP in OPD to measure these variables may help to define how to influence the
experience of patients positively.
Phase 2: Adaptation

Practices of an ANP should be adapted to the environment, and experience of the
organization and be modified as needed. ANP expected to provide primary care in practice
environments which include the most immediate aspects of support:
Becoming qualified: A nurse who has at least one to two post-registration clinical
experience years has to get the Master of Science (MSc) in advanced nursing practice, and
this will usually be delivered on a part or full-time in universities over two years. The
program runs over four semester’s attempts to integrate theory and practice and also
providing (MSc in Advanced Nursing Practice, Riyadh, Saudi Arabia 2020).
Clinical support: this includes the ability to offer support services to the ANPs through
guiding the person how to deal with the issues within the clinical settings. For example,
opportunities to exchange knowledge and experience with other physicians, consultants.
Organization support: measures will be initiated to reorganise the role of the nurses,
redesign the way tasks are redistributed and at the same time increase channels of
communication to address the hierarchical differences in the organization. Support will be
provided to the ANPs to allow them access interproffesional education and support to deal
with the issues within clinical settings.
KSA support: Develops models along with indicators, assess the population of tomorrow,
establish an agreed vision for the models of ANP based on population needs, and recruit
experienced ANP. Collaboration is also supposed to lead to the development of a better
curriculum that reflects the needs of the profession.
Phase 3: Barriers
The ANP role has not been clearly defined thus making it difficult for them to
practice. This leads to the difficulty of the ANPs working with other professionals due to the
interproffesional challenges that are faced by the teams when working together. In this case
education members of the interprofessional team on how to work with the ANPs is the best

way of ensuring that other professionals and even patients understand the role that these new
clinical professionals play in meeting the healthcare needs. This calls for a plan on how the
roles will be distributed amongst the professional teams with the ANPs on board. The best
way is to empower other professionals with inter-disciplinary skills that will allow the ANPs
to be integrated into the new system Patient acceptance will be the most severe barrier. It
would be a challenge of duties assignments by the fact that patients who have gotten used to
seek services from physicians would be expected to exhibit the same confidence when been
cared for by the ANP. So, It is crucial that patients would be educated on the qualifications,
scope of practice, and the importance of ANP By distributing leaflets and making a TV show
in waiting rooms, then they can be more accepting of receiving care. Moreover, many
obstacles may arise at the start of this project, and the key to manage that conflict is to find
effective facilitators. So, the chief nursing officer (CNO) and the director of the nursing
education department will be the facilitators for this project in order to ensure success in
project delivery. Getting the facilitation will benefit the project in solving potential problems,
increase productivity and efficiency of the team, facilitate training, coaching, workshops,
seminars, consulting, recommendations, overall guidance, and supervision reports.
Phase 4: Implementation
One advanced nurse practitioner will be introduced to a primary health care clinic in
Riyadh in Saudi Arabia. Data will be collected to measure the variables of patient satisfaction
and waiting time through using tools of a questionnaire and measurements of time-in, and
time-out. A nurse who has recently graduated with a Masters of Advanced Nursing Practice
will be invited to be involved in the QI project implementation. In order to be sure that a
work environment enables ANP to perform the best ability and being fulfilled; there are
certain fundamentals which have to be in place as per the following:

Clinical skilled practitioner: the organization is supposed to develop a scope of practice
with protocols and policies that define the relationship between the ANP and other
professionals. The scope of practice will offer direction on the actions, procedures, and
processes on how work will be carried out and how roles will be distributed within the
organization. The core clinical competencies of the ANP has to obtain a comprehensive
history, do a clinical assessment, formulate differential diagnoses, request, understand and act
on diagnostic tests and examinations, formulate an action strategy admit, discharge and refer
a patient dependent on his need. These competencies are supposed to be reflected in the
work-based assessments they will be used to measure the impact of the ANPs in the clinical
environment. Since this is a new role, the ANP needs to be supervised during the practice
process of the new role within the clinical environment. The person supervising the ANP
needs to have the clinical and professional ability to carry out the supervision which is the
reason why the hospital has to define the professional that will be charged with this
responsibility.
Skilled communication: communication is an important element in the nursing profession
thus the reason why the ANP need to have clinical communication skills and knowledge of
using different communication tools for use and collecting of clinical data.
Interprofessional collaboration: The ANP has to lead to the development of common goals
that are supposed to be achieved through developing a clinical environment that allows
collaboration with other professionals.
Effective decision making: ANP must adhere to the organizational and industry policies that
are supposed to be used in making the best decisions within the clinical environment. The
organization also needs to create operational structures for improved decision making
through creating of operational structures for the organization.

Clinic interior design: The clinic must be equipped with an appropriate set of furniture that
will allow for safe storage of medical accessories, interviewing and examining patients. There
is also need for creating an environment that allows the ANP to practice adequately with
other professionals and at the same time deal with the clinical issues that arise.
Data collection
Data will be collected at a primary care setting in the clinic that ANP will work in;
family medicine (FMC).
Inclusion Criteria
 Patients attending the FMC.
 All patients who had no history of critical illness during their visit.
Exclusion Criteria
 patients who were considered as critically ill during their visit
 Patients who attend the other departments within OPD
While the data collection for measuring patient wait time will be conducted at FMC from 1st
January until 1 st May 2021, a four-month project period will be sufficient for data collection.
All patients who attend the clinic during this period will be included according to inclusion
and exclusion criteria. The collection of data will be done five days from Sunday to Thursday
each week.
Patient satisfaction measurement
Patient satisfaction will be determined through the use of a patient questionnaire with
18 questions (Thayaparan & Mahdi, 2013). The questionnaire will be attached with cover
form; the patient will be asked if she/he agrees to fill out the questionnaire or not. The total
satisfaction score will be calculated from the sum of responses to all items. The questionnaire
includes 18 items, each item will be answered on a 5-point Likert scale (1=strongly agree,
5=strongly agree). The possible score range will be 18–54; a lower score indicates greater
satisfaction (Appendix B,C, D, E).

After getting the approval of the IRB, patients will be selected randomly, and All of
these patients met the previously mentioned selection criteria. A copy of the questionnaire
will be mailed with a cover letter explaining the purpose of the questionnaire as investigating
the patient satisfaction to FMS. Patients will not be asked to identify themselves and will be
assured about the confidentiality of their responses. Patients will be asked to complete the
questionnaire anonymously, and they will be advised to place the filled forms in the closed
box that will be there for the questionnaire. To test the statistical significance of group
differences, an Independent t-test, and analysis of variance will be used. Statistical analyses
will be performed using statistical analysis software (SPSS) for Windows.
Patient waiting time measurement
The patients will be contacted and briefed based on the criteria previously mentioned
on how they will be involved in the process. The standard of the study will be defined by the
waiting time that the patient took at each stage before seeing the doctor or the clinical
professional and is not supposed to exceed 30 minutes which will be recorded in Appendix F.
Each of the patient will be given a timing form with demographic details that are to be filled
at each station. The nursing staff will record vital signs while the doctor will record
consultation time. The data collected from here will be recorded into SPSS for descriptive
analysis through T-test for significance and a p-value set at <0.01. The measurement results
of both; patient satisfaction and patient waiting time will be presented at a clinical meeting.
Recommended changes and improvements will be estimated.
Phase 5: Monitoring and Evaluation of Outcomes
The evaluation plan will include using Statistical Package for the Social Sciences
(SPSS) to analyse all relevant data being recorded. These statistics will help to judge the
practical importance of the statistically significant findings pre and post introducing the ANP
in FMC.

Phase 6: Sustainability
When the process of setting out the ANP responsibilities started, that means there will be a
necessity for evaluating the ANP role viability and also an examination of ANPs numbers
that might be required in the OPD. Furthermore, the evaluation of the guidelines based on
the monitoring results will help to make necessary arrangements to develop a clear ANP
scope of practice, expected competencies, standards, and associated policies. Evaluating the
results will determine if there will be a need for additional ANPs or not. Patients’ needs and
preferences will be considered as required; however, the ANP aims to provide care across the
age ranges genders.
Ethical Considerations
Ethics are principles that govern professionals on how they are supposed to conduct
themselves through determining the right and wrong. This determines the decision making
process that professionals are supposed to consider when dealing with clinical issues (Trobec
& Starcic 2015). To practice competently with integrity, nurses, like all healthcare
professionals, must have regulation and guidance within the profession (Epstein and Turner
2015).
An institutional review board (IRB) is a type of board that involves QI project ethics
by reviewing the methods proposed to guarantee that they are ethical. This QI project will be
presented to IRB to seek an ethical approval that will ascertain that the plan is being
conducted in a responsible way. Implied consent will be attached to the questionnaire to
inform the patient about patient satisfaction investigating purpose and if he/she wants to fill it
and be involved as participant in this project. The project is aiming to produce positive
outcomes and avoid exposing the participants to risks.
The ANP must be responsible to the profession, the patients being served and
him/herself through upholding the ethical standards. Ethical boards are supposed to be
established so that they can put measures in place to address the issues within the
organization. ANPs are supposed to practice within the primary healthcare requirements that
need to be addressed.

5.0 Data Analysis
The data that will be collected on the variables of patient’s waiting time and
satisfaction, two-month prior, and two-month post the introduction of the ANP will be
evaluated and analyzed. That is, the significant change in these variables post the introduction
of an ANP will be used to indicate the effectiveness and efficiency of the role of ANPs in the
primary healthcare setting. The total of patients’ data will be about 800 if ten patients from all
FMC clinics collected daily in five days each week from Sunday to Thursday. Patients who
will be attending the clinics during this project period from 1 st January until 1 st May 2021
will be collected randomly.
Patient satisfaction
Content validity will be tested through using the questionnaire to assess the validity of
the content. Patients might be satisfied or dissatisfied with the FMC services according to the
mean rating percentage. The score of 36 or less indicate that the patient is satisfied while the
score of 72 or more show dissatisfaction.
Patient waiting time
The ANP introduction is supposed to lead to reduced waiting time thus making it fall
below the 30 minutes threshold. The majority of patients might be waiting for less or more
than 30 minutes in total from registration until getting the appointment. The system will
categorize the mean time for all stages, and it will find the longest and shortest time for
patients. Independent T-test will show significant results (p-value) for pre ANP introduction
versus post ANP introduction.
6.0 Discussion
The major purpose of this QI project is to examine the relationships between the
scores of patient experiences, and the new ANP that will be introduced among primary

healthcare settings in KSA. This includes patient waiting times and patient satisfaction.
Proposing to introduce the ANP to OPD was because: the role of ANP still not been officially
introduced in KSA (ABoshaiqah, 2015), However, the introduction of the ANPs can be an
important improvement of the primary care framework since these professionals are part of
improving medical services and addressing the challenges that are faced by the imbalanced
proportion of general practitioners which is due to increased population and increasing
healthcare needs of patients (Oliver, 2017).
Also, the American Association of Nurse Practitioners (2013) asserts various unique
roles for ANPs in primary care settings. Order and interpret diagnostic studies (e.g., EKGs,
and x-rays, lab tests). They are also charged with the responsibility of prescribing medication
and therapy for acute and chronic illness (extent of prescriptive authority varies by country
regulations). Sometimes they act as primary educators through teaching and counselling
families, stress health promotion and disease prevention which are all played by the general
practitioner. However, like any other professional, the primary ANP is supposed to identify
the limits of their expertise and consult with other healthcare stakeholders in providing and
resolving the issues that patients face within clinical settings (AANP, 2013).
One ANP is proposed to be introduced to the family medicine clinic in order to
evaluate the impact of ANP role on patient experience through measuring patient satisfaction
and waiting time. The KTA framework will guide the methodology and the data analysis
where the two tools of questionnaire and measurement of time-in, and time-out are proposed
to be used, SPSS is chosen to analyse all the data that will be collected. There are no findings
detected right now because this project is a proposal, but it is hoped that it will show positive
outcomes of high satisfaction percentage among patients with a reduction in waiting times
maximizing patient satisfaction and lowering the wait time. This leads to increased patient
satisfaction and improved hospital image which will be reflected in return patients.

Limitations
One of the limitations of this project is that there is only one nurse proposed to
undertake the role of the ANP. This may not show a statistical significant difference pre and
post intervention. It also limits the generalizability of any findings. Another one is the lack
of any historical information on the psychological measurement features of the patient
satisfaction tool.
Recommendations
Introducing the role of the ANP to a primary care setting will increase the patients’
knowledge of the ANP role. While, the ANP role is relatively still unknown and ANPs who
are in practice are challenged by challenges like requesting the lab test or other element of
their potential scope of practice. The new ANPs in the OPD must show that their role will
generally speak and will be positively received through expressing confidence, trust in their
role and by getting patients consideration that ANPs can lead to improved patient satisfaction
and quality care. By highlighting the importance of improving the outcomes of patient
satisfaction and waiting time in the OPD, the organization must continue to expand the
number of ANPs and find ways to measure and improve patient experiences relating to them.
7.0 Conclusion
From the above data, the ANP role in this country needs to be defined so that they can
be involved in clinical service delivery leading to improved quality care. This can be
achieved through legislation of new policies that will define the role of ANPs in the clinical
environment and defining the type of model that will be used in defining the relationship that
they have with other professionals. Further, leadership needs to define the appropriate tools
that are required by the ANPs in meeting their needs. This will create an environment that
allows the ANPs to work and coordinate well with other professionals.

Further, there is need for professional development and identifying the education
areas that these professionals require which can be implemented within the clinical
environment. Therefore, caring for patients is supposed to be the driving factor in the clinical
environment which will ensure that solid foundations are laid to improve the challenges that
patients face in the clinical environment. The increased clinical profession shortages have led
to high health care demands that are required to improve the healthcare outcomes. This
means that introducing ANPs through adequate legislation is the best way of improving the
healthcare challenges being faced and creating an environment that reflects the changing
needs of the country. In this case, it means that recognising the role of ANPs through
legislation is the best way of improving the clinical experience of patients and at the same
time addressing the shortage of staff that are leading to poor patient experience.
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