Patients’ Evaluations of Gynecologic Services Provided by Nurse Practitioners J. M A R K WAGENER, PH.D.* A N D GLENNA CARTER, B.S.N.” Oregon State University
Abstract The development, operating principles, and users’ evaluations of a broad-based gynecologic program emphasizing effective birth control on a university campus are discussed. A major feature that is explored is the use of nurse practitioners as the primary service providers. The forces that resulted in the formation of the program and the methods used to enhance its effectiveness are described. The evaluations of 3,527 users over a three-year period are indicated by summarizing responses to a questionnaire covering the following topics; whether providing such a service was helpful, likelihood of arranging for the service elsewhere i f unavailable at the health center, attitudes of staff; medical procedures used, availability of services, and the opportunity to thoroughly discuss concerns. The evaluations were seen as extremely supportive of both the program and the use of nurse practitioners in this setting. The Student Health Center at Oregon State University has undergone a major change during the past decade in the provision o f birth control and pregnancy counseling services. This change has been the development o f a comprehensive gynecologic program which incorporates the use o f nurse practitioners as the primary providers o f service. Although the Council o f Delegates at the Fifty-Fifth Annual Meeting o f the American College Health Association recognized the expanded role being played by nurse practitioners and voiced i t s support,l reports in the literature on patients’ evaluations o f the use o f nurse practitioners in student health services have been s p a r ~ e . ~The , ~ purpose o f this article i s to describe the current program and i t s development and to report on the level o f satisfaction indicated by students who used the services during a three-year period. The provision o f birth control and pregnancy services became an issue o f open discussion toward the end o f the 1960s. A t that time the Health Center was operating under a policy that emphasized that each physician practiced medicine as he/ she saw fit, and each developed his/her own approach to these services. This resulted in a haphazard situation in which the reception received by a student requesting services o f this nature varied from one o f refusal to .deal with the problem to that o f providing extensive support, depending on the physician seen. The inadequacy o f this policy became more obvious as the number o f women coming t o the Health Center with unwanted pregnancies escalated rapidly, and the resulting demands for medical and psychological intervention became a pressure affecting the availability o f previously established services. The proposed solution t o this problem was to begin to deal with the sexual behavior o f students more openly and t o provide a program emphasizing effective pregnancy prevention procedures. This suggestion was controversial and opinion was *Clinical Psychologist, Student Health Center, Oregon State University, Corvallis, Oregon 97331 ?Women’s Health Care Nurse Practitioner, Student Health Center, Oregon State University, Corvallis, Oregon 97331
98
divided among Health Center and university administration staff on whether such a program should be instituted. Students provided strong support in the form o f individuals requesting services and through a resolution passed by the advisory health committee. The local Planned Parenthood organization was helpful by providing social support and educational materials for the program. A decisive factor was the availability o f a one-year financial grant from the Department o f Health, Education, and Welfare for the development of a pilot program o f family planning services. The result o f this interaction was the decision to develop a broad-based gynecologic services section as a subunit of the Health Center. The program has been expanded considerably since approval o f the federal grant for the academic year o f 1971-72. Students initially became aware o f the services being offered through articles in the student newspaper, presentations by Health Center staff to various living groups and classes, and by word o f mouth. Requests for service were heavy, and it soon became apparent that the one part-time physician and one part-time nurse assigned to this area would be unable to meet demands. The decision to use nurse practitioners t o expand this service was based on economics as well as a recognition that it would be preferable to use the physicians’ time to treat pathology, since this appeared to be more consistent with their training and preference. The number o f personnel working in the area was gradually increased to include two fulltime women’s health care nurse practitioners, one full-time registered nurse, and two receptionist-nursing assistants. In addition to the supervising physician, an obstetrician-gynecologist serves as a consultant. The high usage o f the service is illustrated by the total o f 7,553 patient visits last year t o the gynecologic section. The evolution o f a gynecologic subunit required the cooperation o f nursing, physician, and mental health staff members. Previous articles have described the Mental Health Clinic’s involvement in such activities as counseling for elective abortion,4 intervention in a variety o f sexual concerns o f stud e n t ~ ,and ~ the use o f student volunteers as birth control educatos6 Many o f these activities have been taken over by J.A.C.H.A.
GYNECOLOGIC EVA L UA TlON
the gynecologic staff. Several of the physicians chose to participate initially by performing the physicial evaluations. Currently, a physician provides supervision, prescribes, and evaluates abnormal conditions. Nurses pursued additional training and since then have provided the direct services required by the program. The primary activity by the gynecologic staff i s the provision of information, examinations, and materials for effective birth control. Pregnancy testing and counseling are also available. Abortion referral and follow-up is provided for those who choose this alternative. Women who decide t o remain pregnant receive limited prenatal care prior to referral. The gynecologic section also provides diagnosis and treatment of gynecologic dysfunctions and venereal diseases. While attending to the physicial needs of patients, the staff has attempted to create an atmosphere that minimizes problems reco nized as interferring with patient-gynecologist relationships. 89 A running commentary of procedures and findings is given to increase patient knowledge and reduce emotional discomfort‘. The provision of a mirror so that the patient may view the pelvic exam exemplifies this orientation. Female s t a f f members who can comfortably and nonjudgmentally discuss sexual matters are used. I n discussing birth control or pregnancies, all alternatives are explored while emphasizing that the individual should choose what is best for her. The role that men play in effective birth control i s emphasized, and the patients are encouraged to involve their partners in the decision making as well as in the use o f birth control devices when practical. Brightly decorated rooms and colorful uniforms encourage a relaxed atmosphere. A thorough discussion o f any sexual concerns i s encouraged, and those individuals experiencing unusually severe emotional disruption are referred to the Mental Health Clinic. Education has been strongly emphasized throughout the program. As a requirement of the one-year HEW grant, all recipients attended a small group meeting discussing the methods of birth control. An innovative feature o f this class was a discussion of the psychological aspects of sexuality and their relation to effective birth control. This aspect of the class was initially provided by a mental health staff member, but was eventually taken over by a member o f the gynecology staff. This format has been retained in the optional classes which continue to be offered regularly. The use of this class has lessened as alternative methods of acquiring this information have been developed on campus. The Health Center staff has actively supported dissemination of sexually related information by a variety of means. It assisted in the development of a very popular human sexuality class and has provided input for health classes that have covered these topics. A self-learning center in the waiting room o f the gynecologic area provides information on birth control methods, genetic counseling, pelvic and breast self-exam, and related subjects. Educational pamphlets are widely distributed on campus. Health Center staff members have frequently given informal talks to various living groups and classes. Students have also taught classes or provided individual instruction on relevant subjects under the direction of Health Center staff.
?
Method Users of the gynecologic services were encouraged to provide input into the program through completing a questionnaire developed to assess their satisfaction with the treatment. This questionnaire covered the following topics: whether providing such a service was helpful, likelihood of arranging for the service elsewhere if unavailable at the Health Center, attitudes of staff, medical procedures used, availability o f servVOL. 27, OCTOBER 1978
ices and th opportunity to discuss concerns thoroughly. All patients were encouraged to answer the questionnaire at the end of their last scheduled contact. Responses were tabulated for all evaluations returned for the academic years 1974-75 through 1976-77.
Results Three thousand five hundred twenty-seven women completed the questionnaire. Of these, the gynecologic staff determined that the primary service performed was provision of birth control methods-64%, treatment of a physicial condition unrelated to pregnancy-32%, and pregnancy confirmation and management-+%. The patients indicated that their primary reason for making the initial contact was as follows; 47% for birth control methods, 29% for examinations o f a physical condition unrelated to pregnancy, 11% for pregnancy or possible pregnancy evaluation, and 13% for a combination of the above (generally birth control and possible pregnancy). The evaluative questions are listed in Table I, along with the response rates totaled for the three academic years. Response rates varied less than two percentage points among the three years surveyed for all but one of the questions. The exception was found with the question regarding satisfaction with the availability of services. The proportion answering “excellent” to this question rose 25% between 1974-75 and 1975-76, and it remained high the third year. This represented a signifi= 125.43, d f = 2, cant increase in patient satisfaction p .001).
(x2
Abstract The development, operating principles, and users’ evaluations of a broad-based gynecologic program emphasizing effective birth control on a university campus are discussed. A major feature that is explored is the use of nurse practitioners as the primary service providers. The forces that resulted in the formation of the program and the methods used to enhance its effectiveness are described. The evaluations of 3,527 users over a three-year period are indicated by summarizing responses to a questionnaire covering the following topics; whether providing such a service was helpful, likelihood of arranging for the service elsewhere i f unavailable at the health center, attitudes of staff; medical procedures used, availability of services, and the opportunity to thoroughly discuss concerns. The evaluations were seen as extremely supportive of both the program and the use of nurse practitioners in this setting. The Student Health Center at Oregon State University has undergone a major change during the past decade in the provision o f birth control and pregnancy counseling services. This change has been the development o f a comprehensive gynecologic program which incorporates the use o f nurse practitioners as the primary providers o f service. Although the Council o f Delegates at the Fifty-Fifth Annual Meeting o f the American College Health Association recognized the expanded role being played by nurse practitioners and voiced i t s support,l reports in the literature on patients’ evaluations o f the use o f nurse practitioners in student health services have been s p a r ~ e . ~The , ~ purpose o f this article i s to describe the current program and i t s development and to report on the level o f satisfaction indicated by students who used the services during a three-year period. The provision o f birth control and pregnancy services became an issue o f open discussion toward the end o f the 1960s. A t that time the Health Center was operating under a policy that emphasized that each physician practiced medicine as he/ she saw fit, and each developed his/her own approach to these services. This resulted in a haphazard situation in which the reception received by a student requesting services o f this nature varied from one o f refusal to .deal with the problem to that o f providing extensive support, depending on the physician seen. The inadequacy o f this policy became more obvious as the number o f women coming t o the Health Center with unwanted pregnancies escalated rapidly, and the resulting demands for medical and psychological intervention became a pressure affecting the availability o f previously established services. The proposed solution t o this problem was to begin to deal with the sexual behavior o f students more openly and t o provide a program emphasizing effective pregnancy prevention procedures. This suggestion was controversial and opinion was *Clinical Psychologist, Student Health Center, Oregon State University, Corvallis, Oregon 97331 ?Women’s Health Care Nurse Practitioner, Student Health Center, Oregon State University, Corvallis, Oregon 97331
98
divided among Health Center and university administration staff on whether such a program should be instituted. Students provided strong support in the form o f individuals requesting services and through a resolution passed by the advisory health committee. The local Planned Parenthood organization was helpful by providing social support and educational materials for the program. A decisive factor was the availability o f a one-year financial grant from the Department o f Health, Education, and Welfare for the development of a pilot program o f family planning services. The result o f this interaction was the decision to develop a broad-based gynecologic services section as a subunit of the Health Center. The program has been expanded considerably since approval o f the federal grant for the academic year o f 1971-72. Students initially became aware o f the services being offered through articles in the student newspaper, presentations by Health Center staff to various living groups and classes, and by word o f mouth. Requests for service were heavy, and it soon became apparent that the one part-time physician and one part-time nurse assigned to this area would be unable to meet demands. The decision to use nurse practitioners t o expand this service was based on economics as well as a recognition that it would be preferable to use the physicians’ time to treat pathology, since this appeared to be more consistent with their training and preference. The number o f personnel working in the area was gradually increased to include two fulltime women’s health care nurse practitioners, one full-time registered nurse, and two receptionist-nursing assistants. In addition to the supervising physician, an obstetrician-gynecologist serves as a consultant. The high usage o f the service is illustrated by the total o f 7,553 patient visits last year t o the gynecologic section. The evolution o f a gynecologic subunit required the cooperation o f nursing, physician, and mental health staff members. Previous articles have described the Mental Health Clinic’s involvement in such activities as counseling for elective abortion,4 intervention in a variety o f sexual concerns o f stud e n t ~ ,and ~ the use o f student volunteers as birth control educatos6 Many o f these activities have been taken over by J.A.C.H.A.
GYNECOLOGIC EVA L UA TlON
the gynecologic staff. Several of the physicians chose to participate initially by performing the physicial evaluations. Currently, a physician provides supervision, prescribes, and evaluates abnormal conditions. Nurses pursued additional training and since then have provided the direct services required by the program. The primary activity by the gynecologic staff i s the provision of information, examinations, and materials for effective birth control. Pregnancy testing and counseling are also available. Abortion referral and follow-up is provided for those who choose this alternative. Women who decide t o remain pregnant receive limited prenatal care prior to referral. The gynecologic section also provides diagnosis and treatment of gynecologic dysfunctions and venereal diseases. While attending to the physicial needs of patients, the staff has attempted to create an atmosphere that minimizes problems reco nized as interferring with patient-gynecologist relationships. 89 A running commentary of procedures and findings is given to increase patient knowledge and reduce emotional discomfort‘. The provision of a mirror so that the patient may view the pelvic exam exemplifies this orientation. Female s t a f f members who can comfortably and nonjudgmentally discuss sexual matters are used. I n discussing birth control or pregnancies, all alternatives are explored while emphasizing that the individual should choose what is best for her. The role that men play in effective birth control i s emphasized, and the patients are encouraged to involve their partners in the decision making as well as in the use o f birth control devices when practical. Brightly decorated rooms and colorful uniforms encourage a relaxed atmosphere. A thorough discussion o f any sexual concerns i s encouraged, and those individuals experiencing unusually severe emotional disruption are referred to the Mental Health Clinic. Education has been strongly emphasized throughout the program. As a requirement of the one-year HEW grant, all recipients attended a small group meeting discussing the methods of birth control. An innovative feature o f this class was a discussion of the psychological aspects of sexuality and their relation to effective birth control. This aspect of the class was initially provided by a mental health staff member, but was eventually taken over by a member o f the gynecology staff. This format has been retained in the optional classes which continue to be offered regularly. The use of this class has lessened as alternative methods of acquiring this information have been developed on campus. The Health Center staff has actively supported dissemination of sexually related information by a variety of means. It assisted in the development of a very popular human sexuality class and has provided input for health classes that have covered these topics. A self-learning center in the waiting room o f the gynecologic area provides information on birth control methods, genetic counseling, pelvic and breast self-exam, and related subjects. Educational pamphlets are widely distributed on campus. Health Center staff members have frequently given informal talks to various living groups and classes. Students have also taught classes or provided individual instruction on relevant subjects under the direction of Health Center staff.
?
Method Users of the gynecologic services were encouraged to provide input into the program through completing a questionnaire developed to assess their satisfaction with the treatment. This questionnaire covered the following topics: whether providing such a service was helpful, likelihood of arranging for the service elsewhere if unavailable at the Health Center, attitudes of staff, medical procedures used, availability o f servVOL. 27, OCTOBER 1978
ices and th opportunity to discuss concerns thoroughly. All patients were encouraged to answer the questionnaire at the end of their last scheduled contact. Responses were tabulated for all evaluations returned for the academic years 1974-75 through 1976-77.
Results Three thousand five hundred twenty-seven women completed the questionnaire. Of these, the gynecologic staff determined that the primary service performed was provision of birth control methods-64%, treatment of a physicial condition unrelated to pregnancy-32%, and pregnancy confirmation and management-+%. The patients indicated that their primary reason for making the initial contact was as follows; 47% for birth control methods, 29% for examinations o f a physical condition unrelated to pregnancy, 11% for pregnancy or possible pregnancy evaluation, and 13% for a combination of the above (generally birth control and possible pregnancy). The evaluative questions are listed in Table I, along with the response rates totaled for the three academic years. Response rates varied less than two percentage points among the three years surveyed for all but one of the questions. The exception was found with the question regarding satisfaction with the availability of services. The proportion answering “excellent” to this question rose 25% between 1974-75 and 1975-76, and it remained high the third year. This represented a signifi= 125.43, d f = 2, cant increase in patient satisfaction p .001).
(x2
