Summary
This study identified that general practice websites did not clearly and consistently provide information about different professional groups. Professional roles were not well explained, especially for PNs and ANPs, constituting a missed opportunity to direct patients to members of the wider healthcare team and consequently relieving pressure on GPs. This was underpinned by the assignment of differing levels of professionalism to different professional groups, reflecting traditional perceptions of medicine and nursing, which potentially perpetuates, rather than expands, public perceptions of healthcare providers.
Decision making was largely kept within the practice, rather than providing patients with information to support them to make appropriate decisions about healthcare provider choice. This limited rather than promoted patient-centredness. The presentation of professional roles on practice websites made it difficult for patients to decide the most appropriate practitioner to consult. This can be seen as counterproductive to the current agenda of effectively signposting patients to different healthcare professionals.
This study explored the previously under-researched representation of professional groups on general practice websites. It highlighted that little focus was given to professional group representation. The extent to which patients could be involved in decision making about healthcare providers was limited by the quality and consistency of information provided. These findings highlight a missed opportunity to maximise the potential of websites to promote professional roles and new ways of working, in order to effectively direct patient flow to the most appropriate practitioners. Fundamentally there appear to be issues about who, and what, practice websites are for and whether they best serve patients or practices.
Comparison with existing literature
This study explored how GPs, PNs, and ANPs were represented on general practice websites, in order to assess the extent to which practices provided information to signpost patients to different healthcare professionals and promote patient choice in relation to providers. Although most practices did not state the intended aims of their website provision, it is reasonable to assume that public-facing websites would play some role in providing information to patients about who to consult with. However, even when websites were presented as a mechanism for communication and information sharing with patients, thus enabling patient choice, findings indicated that information was lacking. There was an inability to describe professional roles to the public in a way that provided clear, consistent, and accurate information to allow informed decisions about consultation choice. Websites also failed to grasp the opportunity, promoted by policy, to direct consultation traffic away from GPs towards a variety of appropriate healthcare professionals.3,4,9 Consequently, websites did not explain workforce roles and promote patient choice. This is important because to change public behaviour it is necessary, in part, to provide accurate and appropriate information.
A lack of attention to the outward-facing presentation of practices to the public was evident across websites, which were unclear in purpose and uninspired in presentation. They lacked quality, accuracy, and consistency in presentation of, and signposting to, different professionals. Although this may be attributable to limited information technology support or public relations inexperience, the level of importance practices placed on their websites as a means of communication with patients, and consequently the public image of their workforce, did not appear well considered. This is consistent with research indicating general practices in England have been slow to appreciate information technology as a patient information resource,23 while low-quality information on practice websites has been identified previously.15 It has been suggested that many practice websites are little more than ‘electronic nameplates’.24
Consequently, practice websites can be seen to fail to explain and normalise contemporary healthcare professional roles to the public. This has implications for patient decision making and acceptance of healthcare practitioners more broadly.
There was limited information available on practice websites in relation to ANPs and nursing specifically. That nursing lacks visibility on healthcare provider websites was identified in previous international and North American studies of secondary care websites, which found nursing content inadequate and difficult to locate.11,16,17 Furthermore, a study of English general practice websites, which did not include ANPs, found a disparity in presentation of medical and nursing qualifications.15 Inequitable presentation of professional qualifications is significant on two levels. Lack of presentation of nursing qualifications can be seen to position nursing as less professional than medicine, which may in itself influence patient choice when deciding who to consult. Moreover, although it cannot be assumed that patients understand professional qualifications, patients are able to research these if they so wish. However, as ANP and nurse qualifications are less likely to be provided than GPs’, patients are prevented from accessing this information for these professional groups.
That GPs were more visible and consistently represented than practice nurses and ANPs, whose roles are less well defined, is perhaps not unsurprising considering that GPs were predominantly the owners of general practices in this and other studies.25 As a consequence they were potentially influential in directing what information was included on websites. However, because the GPs’ role and public image is already well established and understood within public expectations, this has implications for public understanding of different roles and the direction of patients to new consultation models. If patients are expected to consult with practice nurses and ANPs as alternatives to GPs in appropriate situations, the lack of visibility and clear information about the specific skills these practitioners offer may limit patient understanding and trust. For patients and the wider public to be able to appraise roles and level of practice, as well as to self-direct to their consultation choice, it is crucial that healthcare professional roles are transparent and the competence of all healthcare professionals recognised.
Websites appeared to reinforce traditional and established notions of the professional hierarchies and identities of medicine and nursing, and the disparity of status between professional groups. Whether these representations were planned or subconscious is unclear. That websites often appeared to be based on pre-designed templates and pre-populated texts suggests this reflects understanding at a wider societal level. It has been suggested that established perceptions of healthcare hierarchies are so entrenched that they have become implicitly accepted.26 As a consequence, despite evolving nursing roles, perceptions of nursing remain largely static.
That ANP practice is poorly described on websites can be seen as a consequence of the inability of the nursing profession to clearly define and articulate what is meant by advanced nursing.27 In the UK, ANPs as a profession lack educational standardisation in terms of competencies and level of qualification.1 This contributes to lack of understanding of advanced practice roles, making it difficult for practices to describe advanced practice in an informative and consistent way. As a consequence, nursing representations remain largely framed within traditional expectations of nursing. If contemporary role descriptions and levels of practice are not made explicit, it is difficult for patients to make informed choices and they may instead base understanding of clinical practice on preconceived and stereotypical perceptions of professional roles.28 This may prevent patients from identifying and accepting the most appropriate practitioner to meet their needs and, consequently, compromise the established need to direct patients to a broader range of practitioners
Studies of media images of nursing29,30 have found that established stereotypes continued to inform the public image of nursing despite new role development, thus limiting patient understanding of expanding nursing roles. Although it is imperative that practices represent healthcare professional roles accurately, it is also incumbent on the nursing profession to raise public visibility and promote more contemporary representations of nursing.28,30 It may be difficult for patients to access and accept ANPs and PNs due to simple lack of awareness about the role, while failing to adequately state professional skills, qualifications, and experience equitably may lead to alternative practitioners being viewed as less able to deal with complexity of care.31 This may affect patients’ willingness to consult with practitioners other than GPs.32
Websites were also found to limit patient decision making through reserving privileged information within practice structures, for example, by using receptionist triage instead of publishing adequate information for patients to make appropriate decisions. If the criteria by which patients can identify appropriate practitioners are not made transparent patients may feel funnelled towards different practitioners by stealth. That many websites failed to promote patient choice requires exploration. Although recent attempts have been made to shift to more equal positioning of professionals and patients,12 traditional relationships between professionals and patients within primary care consultations persist.33 Websites may be seen as an extension of this.
Dissonance has also been identified in medical practitioners, brought about by tensions created by the pragmatic necessity to permit other practitioners to provide healthcare services and an underlying drive to protect territory and practice traditionally perceived as within a medical remit.34 Inequitable and unclear website representations of different professional roles may demonstrate similar dissonance.
Implications for research and practice
By using general practice websites more effectively, professional roles may be better understood and utilised by patients. Effective direction of patient flow, normalisation of different professional roles, and increased patient choice have the potential to be promoted through website information. This can be supported by:
ensuring all professions are represented clearly, consistently, and accurately, in a manner that can be easily understood and compared. This allows patients to make appropriate choices in relation to healthcare providers; and
developing website structures and text that innovatively and accurately reflect contemporary healthcare delivery.
Findings from this study may inform future representation of newer non-physician practitioner roles such as physician associates and advanced clinical practitioners from various professions.
This preliminary study in an emerging area of research highlighted several strands of future research meriting further exploration, and identified a number of important areas beyond the scope of the exploratory nature of this study. Exploration of UK secondary care website provision and comparison against the international context of competitive, fee-for-service healthcare systems would broaden the application of future studies. Understanding what practices want to achieve from their websites would also be of value.
Future research would benefit from gaining patient and public input into how website information was understood and interpreted; how patients make decisions about providers; whether (and how) websites are used in patient decision making; what information patients require in order to make informed decisions; and how websites can be more effectively used to channel patient behaviour. Exploration of other forms of new media, such as Facebook and Twitter, which were beginning to be used by practices in this study, would also aid understanding of how new media, and technology more broadly, can impact patients’ experience and service utilisation.
