2.1 Sample and Setting

In this study, a consecutive sampling strategy was used to target patients seeking primary care. Data were collected at primary care centres in southwestern Sweden. All RNs at the participating primary care centres were approached with a request to collaborate in the study. All patients who visited participating RNs due to a new health problem or a new episode of a current health problem during pre-selected study days were invited to participate. Inclusion criteria were patients aged 18 years or older. All participants provided written informed consent.

Data were collected at 10 primary care centres representing diverse locations and clinic sizes, including both public (n = 8) and private (n = 2) facilities in rural and urban areas. These centres served between 5000 and 12,000 patients. This study is part of the PINPOINT project [21] that, based on a sample size calculation, aimed at recruiting 150 patients.

There are approximately 1200 primary care centres in Sweden, operated by both public and private providers. All primary care is funded through a tax-based healthcare system that ensures coverage for everyone living or working in the country, and care is generally consistent regardless of the provider's ownership [22]. Approximately 40.5 million visits are made annually to primary care facilities, with more than 12 million of these involving RNs. Generally, the RNs' responsibilities range from management of acute and chronic conditions to providing broader support [8]. While most RN visits are assumed to focus on chronic disease management, the proportion of same-day, RN-led consultations for new health problems or new episodes of existing conditions remain unknown. Traditionally, these types of consultations have been the primary responsibility of GPs within the Swedish primary care system.

2.2 Data Collection

The data collection was undertaken between September 2023 and March 2024. Out of 152 eligible patients in the PINPOINT project, 138 patients answered the questionnaire (response rate 95%). Eligible patients who did not participate were mainly unable to do so due to time restraints.

2.3 Instrument

The instrument used for measuring the participants' expectations and experiences in relation to various aspects of communication was the Quality Of communication Through the patient's Eyes (QUOTE-COMM) [17, 23] and has been demonstrated to be feasible and useful [17]. The QUOTE-COMM instrument measures various aspects of communication that have been identified as valuable to patients in terms of both their expectations and their experiences. It contains three scales: a task-oriented scale that assesses different medical content (six items), an affect-oriented scale that evaluates the emotional aspects of the interaction (seven items) and a therapy-oriented scale that measures the therapeutic aspects of the consultation (six items). In total, QUOTE-COMM consists of 19 items reported on four-point Likert scale (1 = not important/no, 2 = fairly important/not really, 3 = important/on the whole, yes and 4 = extremely important/yes). The internal consistency of the questionnaire was assessed using Cronbach's α. For the task-oriented scale, values were a = 0.74 (T0), a = 0.82 (T1) and a = 0.85 (T2). For the affect-oriented scale, values were a = 0.45 (T0), a = 0.56 (T1) and a = 0.69 (T2). For the therapy-oriented scale, values were a = 0.77 (T0), a = 0.74 (T1) and a = 0.69 (T2).

Participants also answered a short questionnaire that contained demographic questions on year of birth, sex, native language and level of education.

2.4 Data Analysis

The analysis was conducted using the Statistical Package for the Social Sciences (SPSS), version 28.

Demographic data is reported with descriptive statistics (i.e., percentages, frequencies, mean, standard deviation, median and interquartile range). Due to the non-normal distribution of the data, non-parametric tests were used, and medians and interquartile ranges were reported. Patient satisfaction was determined through Wilcoxon signed-rank tests, by comparing patient expectations versus immediate experiences (T0 vs. T1), and expectations versus 2 weeks follow-up (T0 and T2).

Multivariate linear regression analyses were conducted to examine associations between patients' age, sex, native language, educational level and consultation length with their expectations (T0), immediate experiences (T1) and patients' experience at 2 weeks follow-up (T2) related to the RN consultation. Age, length of consultation and education level were dichotomised for analysis. Age was categorised as under 65 years (n = 85) and 65 years or older (n = 53). Consultation length was categorised as either less than 10 min (n = 81) or 10 min and longer (n = 52). Educational level was categorised in primary or secondary education (99 participants) and higher education (39 participants). All tests were two-sided and the significance level was established at p < 0.05.

2.5 Ethical Considerations

Ethical approval was obtained from the Swedish Ethical Review Authority (Dnr Ö24-2023/3.1). Participant sampling, data storage and access followed relevant laws and safety regulations to ensure participants' security, privacy and confidentiality. All participants received detailed information about the study, including the right to refuse, data processing and the right to access their personal data.

3.1 Demographic Characteristics

Sex distribution among the 138 participating patients was balanced between women (n = 75, 54.3%) and men (n = 63, 45.7%). Their ages ranged between 18 and 90 (mean age 55.02, SD 19.36). The majority of the participants reported Swedish as their native language (n = 116, 84.1%), while a smaller proportion had another native language (n = 22, 15.9%). More than half had primary or secondary education (n = 81, 58.7%) or higher education (n = 55, 41.3%). The average duration of the consultation was 10.34 min (SD = 5.75).

3.2 Patients' Expectations of Communication With RNs

Patients reported high expectations (T0) before RN consultations across all three communication scales assessed: task-oriented (median 3.51), affect-oriented (median 3.8) and therapy-oriented (median 3.3)—see Table 1.

3.3 Patients' Experiences of Communication With RNs

Overall, patients also reported their experiences with RNs' communication during consultations as high, both immediately after the consultation and at 2 weeks follow-up. Immediately after the consultation, (T1) patients reported the highest scores on the task- and affect-oriented scales. When comparing expectations before (T0) and experiences immediately after (T1) consultations, patients reported significantly higher scores on the affect-oriented scale (z = −3.174, N-Ties = 119, p < 0.005) after the consultation.

Patients reported their experience at the 2 weeks follow-up (T2) was also high, see Table 1. When comparing total mean scores for patients' expectations (T0) with their experiences at the 2 weeks follow-up (T2), there was no significant difference (z = −0.320, N-Ties = 103, p = 0.748). For the difference scale, a significant difference was found on the task-oriented scale (z = −3.53, N-Ties = 96, p < 0.001), with lower median scores at the 2 weeks follow-up (T2), compared to expectations (T0). On the therapy-oriented scale, the results indicated significantly lower scores (z = −3.319, N-Ties = 67, p < 0.001) for treatment-related aspects of communication when comparing expectations (T0) with immediate experiences (T1) after the consultations, and this difference related to lower scorings remained at 2 weeks follow-up (T2) (z = −3.42, N-Ties = 65, p < 0.001).

3.4 Associations Between Patient Characteristics and Their Expectations and Experiences

No significant differences were found in relation to patients' age, sex and education when comparing their expectations (T0) with immediate experiences (T1) of the RN communication. Patients' native language was associated with lower scores on the affect-oriented scale after the consultation (T1) (B = −218, p < 0.005)—see Table 2.

When comparing expectations (T0) with 2 weeks follow-up (T2), the results indicate a significant association between the length of the consultation and the task-oriented scale (B = 0.31, p < 0.005) as well as the affect-oriented scale (B = 0.30, p < 0.001). Participants with a longer consultation, lasting 10 min or more, reported higher levels of satisfaction with RN communication during the consultation, see Figure 1.

4.1 Strengths and Limitations

There are some strengths that should be highlighted in the current study. The data was collected from different primary care centres that attend to different populations in an urban area. Measurements were taken at three distinct time points, giving patients the opportunity to evaluate their care after some time had passed. Moreover, the results have been discussed with a reference group comprising representatives of patients and RNs.

There are some limitations that should be considered when interpreting the results. Even though participants were recruited consecutively, this may still have resulted in a certain selection bias. Nonetheless, the distribution of patients in the study was diverse in relation to the patients' gender, age and native language, which has a positive impact on the generalisability of the study. Another limitation in the study is the potential confounding resulting from the lack of randomisation. To minimise this risk, multivariate regression analyses were undertaken and the effect of several variables (e.g., age, education, etc.) was controlled for.

Patients who answered the questionnaire generally reported positive experiences. However, the main reason for nonresponse was a lack of time before consultations. The high satisfaction levels could be influenced by the fact that all participants made an appointment with an RN at the primary care centre, whereas those who were advised on the telephone to manage their condition with self-care or wait-and-see were not included in this study. One of the scales of the QUOTE-COMM instrument, the affect-oriented scale, had low internal consistency (Cronbach's α), while the rest of the questionnaire demonstrated acceptable reliability. This may be due to the limited number of questions in this scale [46]. Previous studies have shown some variation in Cronbach's α values [17, 23]. Due to this lower internal consistency, the results should be interpreted with caution. Future research should consider refining this scale. Although the questionnaire used in this study has been applied in primary care settings before [23, 47], it was originally developed to assess physicians' communication during consultations. The RN-led consultations in this study were considered comparable to physician consultations in terms of context and communication focus, supporting the questionnaire's relevance in this context. However, the therapy-oriented nature of the scale posed challenges for some patients, making certain questions more difficult to answer. In some cases, patients found it difficult to distinguish whether specific tasks had been performed by the RN or the physician, which led some to refrain from answering, which may have contributed to a lower response rate. Future research should further examine the applicability of this instrument in an RN context to ensure its validity across different countries and healthcare provider roles.

4.2 Practical Implications