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A Marketing Plan 1

/lncreasing Consumer Awareness of the Role of the Nurse Practitioner in
Primary Care: A Marketing Plan/

Scholarly Project
Michigan State University College of Nursing

Dianna Drach
//

RUNNING HEAD: A Marketing Plan

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Table of Contents
Page

Abstract ............................................................................................. 2
Introduction ................................................... ‘ ..................................... 3
Purpose ............................................................................................... 5
Review of Literature ............................................................................ 5
Conceptual Framework ...................................................................... 13
Figure 1 ............................................................................................... 14
Figure 2 ................................................................................................ 16
Figure 3 ................................................................................................ .22
Methodology .......................................................................................... 23
Plan ....................................................................................................... 24
Process for Implementation ................................................................. .28
Process for Evaluation ........................................................................... 30
Implications for Advanced Practice ...................................................... 32
Recommendations for Education ......................................................... 34
Recommendations for Research ........................................................... 35

References .............................................................................................. 36

A Marketing Plan 2

Abstract
Lack of consumer awareness of the role of the nurse practitioner (NP) is
one of the many barriers mat decrease the utilization of NP services. The
literature indicates that there is a potential market for NP services among
health care consumers, however there is an increase reluctance to utilize
NP services without prior knowledge of the role or previous experience with
the service. The purpose of this project is to increase consumer awareness
of the role of the nurse practitioner in primary are as a means of improving
access and distribution of health care. The basic theoretical framework
was derived from the L. Aday & Anderson (1981) health access model. A
comprehensive marketing plan was developed utilizing a combination of
transactional and relationship marketing strategies (Gronroos, 1990) aimed
at strategic points with in the model. Evaluation of the plan focused on
increase in utilization of NP services from clients, referrals from providers.
and mcognition of role from third party pay sources. Implications for
practice included: developing professional relationships. becoming visible
in a community. increasing education among clients and nursing

education, and continued research in health care marketing.

A Marketing Plan 3

mm:

Nurse Practitioners (NP) have made tremendous contributions to
the quality and availability of health services, particularly in the
underserved areas (May, 1988). A policy analysis, prepared by the office
of Technology assessment of the US. Congress, and the fifth report to the
President and Congress of the Status of Health Personnel in the United
States, prepared by the us. Department of Health and Human Services
(HHS) in December 1986, attest to the utilization of nurse practitioners and
physician assistants in increasing the availability of primary care services
and enhancing patient satisfaction with senrices delivered. as well as
increasing practice productivity and cutting the cost of care.

The annual cost savings to the United States if nurse practitioners
were utilized to their full potential has been estimated to be between $6.4
billion and $8.4 billion (Nichols, 1992). In spite of these facts, nurse
practitioners are not being utilized adequately because of significant
barriers to their practice (Pearson. 1993)

Hallman and Westlund (1983) discussed the Nurse Practitioner
movement in both Canada and the United States which stemmed from a
physician shortage and the recognition that increasing numbers of
physicians would not necessarily increase the quality of health care
delivery. The issue of optimally utilizing well prepared Nurse Practitioners
is complex and involves physician resistance, lack of government initiative.
and nurse's attitudes (Hallman & Westlund, 1983).

A Marketing Plan 4

Pearson (1993) identified that Nurse Practitioners are not being
utilized adequately because of significant barriers to their practice in the
areas of legal scope of practice, prescriptive authority, and reimbursement
Abner and Hawkins (1992) concluded significant barriers to nursing
credibility are in the profession's image is being portrayed in nursing and
medical advertisements within the'nursing and medical journals. Studies
conducted on image of nursing portrayed in advertising demonstrates a.
poor professional image. The term 'midlevel provider’ used in legislative
proposals to categorize nursing practice at advanced levels (which include
CRNA, CNS, NP) is offensive because it endorses an inappropriate I
concept of a hierarchical health care system.

Physician attitude was described as a significant barrier, (Hogan &
Hogan, 1982; Johnson, F reebum, & McCally, 1985; Holbrook &
Shamansky, 1985) confirmed physician attitude as a barrier by limiting
access of NP to the consumer. According to Johnson, Freebum, and
McCally. (1985). a subjective estimate of 83% of adult primary care office
visits could be safely delegated to Nurse Practitioners however, physician's
willingness to debgate visits was actually 52% - 62%.

Hogan and Hogan (1982) identified consumer response to utilization
of Nurse Practitioner services could also be a barrier. They found that
acceptance of the NP role is contingent on experience with a Nurse
Practitioner or knowledge of the Nurse Practitioner role. Role ambiguity
and lack of consumer knowledge are significant barrier to NP practice.

A Marketing Plan 5

Some of the proposals for managed care organizations indicated the
power and authority of the physician in determining who will care for the
client. No reference in these guidelines have been made to NPs, thus
limiting access to patient populations and limiting NP practice. The
nonspecificity of the labels applied to advanced practice creates difficulties
in conveying clear messages about types of providers that are available
and the nature of the services they provide. Multiple barriers to advanced
nursing practice have been identified, for the focus of this project it has
been identified that individual nurse practitioners have the greatest impact
on consumer awareness.

Bum:

The purpose of this project is to evolve a plan to increase consumer
awareness by developing a marketing plan describing the role of the Nurse
Practitioner in primary care as a means of improving access and
distribution of health care. A plan for implementation and evaluation of the
marketing plan will be included.

W: Marketing, role of nurse practitioner, Primary care,
Consumer awareness, Health care access.

8 . [I '! I
I I I |°

The survival and growth of the nursing profession depends upon the
extent to which its services meet society's needs. There is a growing body
of literature suggesting that NPs provide high quality, cost - effective,
acceptable services to clients. (Edmunds, 1978; Fagen, 1982; Sox, 1979;

A Marketing Plan 6

Nichols. 1992; Pearson, 1993; May, 1988; Holbrook & Shaminsky, 1985).
Nurse Practitioners can inform potential consumers about these findings
through the use of marketing techniques. Marketing is not only sales or
promoting; but. is a deliberate activity directed toward achieving
predetermined organizational objectives through the satisfaction of the
needs and wants of the consumer. Marketing is a transition between the
organization and the potential client; or marketing attempts to strengthen
the goodness of fit between the health care services offered and the needs
of the population (Denver, 1984). According to McKenna (1991),
marketing is “integrating the customer into the design process to guarantee
a product that is tailored not only to the customers' needs and desires but
also the customers' strategies.“ (p. 67) Marketing means building
relationships with its customers. Marketing is an intangible that the
customer must experience to appreciate. it is the process of creating a
customer environment of information, assurance, and comfort (McKenna
1991 . p. 69). According to Star (1989). the marketing concept “is
supposed to find out what consumers want or need and try to satisfy those
needs. (p.149). Lazarus, Petras, and Bradford (1992), defines marketing
as that which ”involves determination of customer needs and development
of programs and services designed to satisfy those needs' (p. 55).

For the purpose of this project marketing is defined as the process
which occurs between the provider of the service and the participant. in

order to assure the service provided meets the client need.

A Marketing Plan 7

W
As stated earlier, the literature indicates that there is a potential

market for NP services among healfir care consumers, however NPs must
continue efforts to inform consumers of their services. Whefirer healfir care
consumers would utilize NP services has been examined in several studies
(Brands, 1983; Chenoy, Spitzer, 8 Anderson, 1973; Fox 8 Storms, 1980;
Enggist 8 Hatcher, 1983; Hogan 8 Hogan. 1982; Pender 8 Pender, 1980;
Shamansky, Schilling, 8 Holbrook, 1985;Smifir, & Shamansky, 1983;
Schilling, Shamansky, 8 Swerz, 1985; Zilo'nund 8. Miller, 1979; Kay, 1986;
Cox, Bergen, 8 Norman, 1993; Drury, Greenfield, Stilwell, 8. Hull, 1988;
Greeneich, 1993). Factors found to influence fire use of NP services are
cost of fire services and whefirer firey are covered by healfir insurance; fire
age, sex, educational level, and social status of fire client, fire extent to
which fire services are seen as consistent wifir fire existing norm; fire type
of services sought; and fire prior knowledge of fire NP role. Holbrook 8
Shamansky (1985), concluded firat there is an increase in client reluctance
to utilize NP services wifirout prior knowledge of NP role or previous
experience wifir NP services.

It has been suggested that fire historical absence of consumer
information about price and quality of medical services is fire most
important difference between medical care and nonhealfir goods and
services. (Pauly. 1978). Inadequate consumer information has been cited
as an important factor contributing to “imperfections in fire structure and
fire conduct of the market for health services.“ (Langwell 8. Moore, 1982,

A Marketing Plan 8

Sloan 8. Feldman, 1978). One reason for firis inadequacy is fire historical
prohibition of direct adverfising promoted by state licensing requirements
and professional association codes. These restrictions effectively
increased fire cost of obtaining information and firus discouraged
comparison shopping. Most importanfiy, medical care is sufficienfiy
complex to preclude many consumers from a level of knowledge sufficient
to make informed choices about services. The consumer must rely on fire
physician to interpret services. It is fire physician who subsequenfiy
controls fire decision-making process about fire services to purchase.
(Feldstein, 1 978).

Consumers have traditionally had less information about medical
services firan firey have had about ofirer goods and services; fire literature
reveals some disagreement about how extensive consumer ignorance is
(Benham, 1972; Cady, 1976,; Pauly, 1978). Pauly (1978), suggests firere
are certain groups of services about which consumers can become
informed. These included services used frequenfiy by most households
(roufine healfir exams, dental checkups, and pediatric visits) . Pauly
(1978) suggests firat 25% of related consumer use decision are well-
informed decisions. Traditionally, healfir consumers acquire knowledge of
providers through personal experience or advice from a friend or relative
(Booth 8 Babchuk, 1972).

For purposes of firis project Consumer awareness will be defined as
fire flow of information necessary to forrrr a level of knowledge required of

fire consumer to make informed choices about healfir care services.

A Marketing Plan 9

B I E I l E If

The council of Primary Healfir Care Nurse Practitioner of fire
American Nurses' Association defines fire nurse practitioner as a
“registered nurse prepared firrough a formal, organized educational
program firat meets guidelines set by fire profession.“ This education
prepares fire nurse practitioner to prescribe a full range of primary healfir
services. Practitioners engage in independent decision making about
healfir care needs and provide care to individuals ,1amilies, and groups
across fire life span. (American Nurses, Association, 1985, p.3).

According to Riner , (1989), Nurse Pracfitioners include in fireir
range of activities “physical assessments, healfir promotion, prevention of
disease, and nursing and medical management of disease. " (p226).
Utilization of medical protocols facilitates fire primary care provider's role
by expanding fire nurse practitioners' assessment and intervention options
firrough ordering of prescription drugs, and ofirer treatments traditionally
viewed as wifirin medical practice.

The ANA defined fire nurse practitioner as a “registered nurse who,
firrough sudy and supervised practice at fire graduate level, has become
expert in a defined area of knowledge and practice in nursing“ (ANA, 1980,
p. 23). The role characteristics of fire nurse practitioner is multifaceted,
wifir many components. Fourteen role functions exist for fire nurse
practitioner however. for fire purposes of firis project five role functions will
be discussed.

EI'” |

A Marketing Plan 10

One who formulates nursing diagnoses and provides direct primary
nursing care based on sound fireory and advanced clinical judgmentto
client and fireir families in a variety of healfir care settings to promote self-
care abilities, maintain healfir, prevent complications, cope wifir healfir care
problems, and manage disabilities (NUR 501 clinical syllabus Michigan
State University).
we

Barron discusses fire consultant role of nurse practitioner as
important Caplan (1970) defined consultafion as a process of
communication between professionals. During consultation. a
communication occurs between fire consultant, who is a specialist and a
consultee. The goals of consultation are to improve fire consultee's skill in
handling a problem and to enhance fire consultee's ability to master future
problems of a similar type. This may be accomplished firrough education,
clarification, diagnostic formulation, and additional problem solving
strategies.

W

Expert knowledge and skills in a specialty are utilized by fire Nurse
Practifioner for patient and family education. Clinical expertise and
knowledge enable fire Nurse Pracfitioner to impart cognitive information
and to assist fire pafient with developing judgment.

ResearcbeLBcle
Research ufilization is defined by Mcguire and Harwood (1989), to

include ”identification of researchable clinical problems, provision of

A Marketing Plan 11

consultation in clinical site to researchers, facilitation of collaborafion in
research activities, and conduction of quality assurance investigations.“
(Hambric and Spross 1989, p. 173).

W

Collaboration means “to work togefirer, especially in a joint
intellectual effort.“ (Spross, 1989, p. 208).

The role of nurse practifioner for fire purpose of firis paper is
adapted from Stewart's (1990), concept of “provider as partner ". (p. 19).

The partner role of fire Nurse Practitioner is defined by fire frequency wifir
which firere is joint exchange of information and joint decision making
regarding goals and methods to achieve goals between nurses, client and
fireir families followed by mutual working to achieve goals and joint
evaluation of effectiveness of emofional and physical outcomes. (Stewart,
1990, p.19). it is furfirer demonstrated by fire degree to which firere is
observable and perceived equality in levels of status, control, and
responsibility in relafionships with ofirers.

EflmanLQate.

Primary care reflect a philosophy of citizen involvement. According
to Stewart (1990), component of primary healfir care include; “self care,
mutual aid, public participation, creafing of supportive environment, team
work, wifir lay helpers, and community based care.” (p. 19). Safriet
(1992), defines primary care as a "basic level of healfir care, usually
provided in an outpatient setting, firat emphasizes a patients general
health needs.“ (p. 422). The most frequenfiy emphasized aspect of

A Marketing Plan 12

primary care focus on ”first contact care which is assessable,
comprehensive, coordinated, continuous and accountable. (Safriet 1990.,
pg. 422). 'The patient - oriented rafirer firan disease oriented focus on
primary care emphasizes preventative measures, such as immunizations,
and healfir assessment, as well as fire diagnoses and management of
commonly occurring condition such as acute and chronic illness.“ (Safriet
1990, p. 422).

For fire purpose of firis project primary care will be defined as
holistic services based on prevention, utilizing assessment, planning,
intervention and evaluation techniques.

Am

Access has been termed “fire availability of resources necessary for
an individual to enter fire system, fire process of gaining entry, and fire
actual need of medical care.“ (Aday 1976 p. 215). Aday (1976), states fire
indicators of potential access to fire healfir care system are a regular source
of medical care. and fire perceived need for healfir care. (p. 372). The
criterion is operational in terms of minimum service, fire identification of
“pockets“ of observed morbidity, or measures of fit between observed need
and obtained services. According to Anderson and Aday (1978), access
has been defined as :

1. availability of healfir facilities and personnel (i.e., physicians to

population ratios); 2. fire various costs of using these facilities and

personnel 0.e., out of pocket cost to fire consumer, travel time to a

regular source of care, waiting time in the physician's office); 3. fire

A Marketing Plan 13

actual use of fire service (i.e., fire proportion of people who see a
doctor in a given period, fire number of visit per person in a given
time period); and 4. fire use of health services relafive to some
measurement of apparent need of fire population for firese services
(i.e., physician visit relative to symptoms perceived, disability
experienced orjudged severity of illness conditions). p. 534.

For fire purpose of firis project access is defined as fire actual utilization of

fire target service.

9911mm;

Aday‘s & Anderson (1981), Health Care Access model provides fire
basic framework for firis project. Aday's model is utilized to relate fire
concept of role, health care access and consumer awareness. Potenfiai
access of fire consumer is related to fire actual awareness of services
provided and realized access is related somewhat to provider

characteristics or role.

 

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A Marketing Plan 14

 

 

 

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A Marketing Plan 15

Gronroos‘ (1990), marketing strategies will be ufilized at different point of
service wifirin fire Aday 8 Anderson (1981) access model to relate fire
concept of markefing, consumer awareness, role, nurse practitioner and
healfir care access.

WM

Aday 8 Anderson (1981), cites diversity of definitions of access in
fire literature. “Researchers have emphasized fire overall availability
(supply) of services, characterisfic of fire people who may potentially avail
firemselves of firese services; considering factors such as fireir income
levels, and insurance coverage“ (pg 5). Recent literature focuses on
defining access as intermediate outcome measures, such as fire roles or
how satisfactory customers perceive fireir care (Greeneich, 1993). Aday
(1981), integrated firese diverse definitions into “firese dimensions which
describe fire potential and actual entry of a given population group to fire
healfir care delivery system“ (p. 5). Potential access is divided into
structural (availability and organizational) and process indicators (
predisposing factors, enabling factors, and need). Realized or actual
access is divided into subjective (customer satisfaction) and objective
indicators (utilization of services).

Structural indicators of potential access are fire characteristics of fire
health care delivery system which includes; Availability of services, fire
volume and distribution of services. and organization of fire structure's
accessibility. Process indicators for potential access are fire characteristics

of fire population at risk which includes; predisposing risk factors,

A Marketing Plan 16

(behavior, environmental, heredity, age), enabling factors, and perceived
need. The objective indicators of actual access include customer
satisfaction, (convenience, availability, financing, provider characteristics,
and perceived quality).
I l l I. E! I .

The principles of Gronroos' (1990), marketing orientation utilize a

combination of transactional and relationship marketing.

 

 

 

 

 

 

 

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Wm- Picture 2

A Marketing Plan 17

The center of the process is fire “moment of truth“ of fire buyer -
seller interactions (Gronroos, 1990). in fire moment of trufir fire value to
fire customer is created. If the customer are not taken care of properly, fire
“perceived service quality, service quality as perceived by fire customer, is
damaged and fire service provider loses return business. According to
Gronroos (1990), The main focus in service competition is fire
management of fire moment of trufir, and fire creation of adequate support
from managers, and supporfing functions as well as from investment in
technology and operation and administrative systems. (p. 257).
Customer's experiences of fire moment of trufir are dependent on certain
expectations, which are created by fire service provider. External
marketing function, involving traditional marketing effort such as market
research, personal selling, advertising, direct mail, sales promotion,
pricing, and public relations, fire organization gives promises, which
hopefully correspond wifir fire personal needs and wishes of fire target
group of customers.

These promises are enhanced or counteracted in fire minds of fire
customer by word-of-moufir communication and by the customers
conception of fire image of fire service provider. Image is a significant
concept involved in marketing communication. A favorable and well-known
image is an asset because image has an impact on customer perceptions
of fire service. Image communicates expectations. A positive image makes
it easier for fire organization to communicate effectively and makes

customers more perceptive to favorable word—of—mouth. A negative image

A Marketing Plan 18

has the opposite effect. A neutral or unknown image may not cause any
damage but does not communicate effectively fire service quality. Image
also act as a 'filter' which influences fire perception of fire organization.
Technical quality (fire product) and functional quality (how fire product is
presented or delivered to fire customer), are seen firrough firis filter. If fire
image is good for example fire filter 'sheiters fire organization. In ofirer
words if fire buyer seller interactions are positive some “flaws in technical
quality are over looked. An unfavorable image makes customers feel more
unsatisfied with bad service firan they ofirerwise would be. A neutral image
does not cause harm however, does not shelter. Image is a function 'of fire
experiences as well as of fire expectations of fire customer. When
customers develop expectations and experience reality in fire form of a
technical and functional quality of fire service, the resulting perceived
service quality changes the image. If the perceived service quality meet
fire image or exceeds it, image is reinforced and improved. if fire
organization performs below image, fire effect will be opposite. lffire image
is not clear it is developed and given distinct features by fire customer
experiences. Image has an internal impact as well. The less clear fire
image fire more firis may reflect employee atfitudes toward fire
organization, which in turn may negatively influence employee customer
relationships.

Gronroos (1990), makes a point to explain firat negative image and
or experiences are communicated faster via fire word-of-moufir

communication cycle firan positive experiences

A Marketing Plan 19

Employees' abilities and motivation to meet fire expectations of
customers are backed up by internal marketing effort. The organization
prepares fire employee to deal effectively with fire moment of truth by
creating and maintaining a service culture. According to Gronroos (1990).
internal marketing is fire responsibility of every manager. Personal needs
of jobs and managers' encouragement of employees, as well as fireir life
pafir and fireir image of fireir employer, also have an impact on fire
employee performance in fire moment of trufir of fire buyer seller
interacfion. Employees are influenced by role ambiguity, related to what
firey perceive customers and fire organization expect firern to do.

What actually happens in fire moment of trufir determines whether
fire experience of fire customers meet fireir expectations. If experiences
equal or are higher firan expectations, fire perceived service quality is
good. Good quality is a strong basis for a long-term customer relationship
and positive word-of-moufir. According to Gronroos (1990), “It is five fimes
easier to obtain repeat business from an existing consumer firan it is to get
new business from a new customer" (p.56).

Fulfilling promises in fire moment of trufir interactions is one of fire
major aspect of fire interactive marketing function. The material support of
support personnel and functions, as well as management support. are
critical to fire service orientation of fire contact persons and systems of fire
visible part of the service production process. The experiences of fire
moment of trufir are influenced by fire image of fire service provider in fire

minds of fire customers. The price level and possible price offerings have

A Marketing Plan 20

an impact on how satisfied customers are wifir fire moment of trufir, if fire

moment of trufir are poor no mater how much a customer can save wifir a

decrease in cost, future sales are lost.

 

The principles of marketing orientation strategy utilize a combination
of transactional and relationship marketing at different point of entry in fire
Aday access model, educating consumers of fire role of nurse practitioners
in primary care and impacting healfir care access. The structural aspect
of potential access defines fire characteristics of the health delivery system
(primary care). Markefing would be accomplished wifir mass marketing, Or
distribufion of brochures, literature and information that defines the holistic
philosophy of nurse practitioners in a primary care setting. Transactional
marketing would also be utilized initially in fire process indicators of
potential access in defining target populations to market nurse practitioner
services, defining populations at risk, and how nurse practitioners can
impact fire process. According to David Hewitt. marketing executive at
Gerber Memorial Healfir Services,‘lt is important to identify key people
wifirin a populations who will positively influence word-of-moufir
communication". He also stated to strengfiren fire image of an unknown
service (or provider) it is imperative to collaboratively market wifir providers
wifir an established positive image (D. Hewitt, personal communication,
June 1994). According to Professor L. Delene Western Michigan
University, image communication is-a significant concept wifir marketing a

service few people are familiar. ( L. Delene, personal communication

A Marketing Plan 21

December 1993). Stated earlier in fire literature review client who have
utilized nurse practitioner services have been satisfied wifir fire services,
however client who have had no experience with the services are
reluctant.

Transactional marketing will be utilized to" create expectations by
giving promises.” The actual process of interacfing with fire population (Le.
identifying predisposing, enabling factors, and perceived need), is based
on relationship or interactive marketing and maintaining these
relationships. Relationship marketing with fire goal of total communication
and image marketing is significant in increasing consumer awareness
regarding objective indicators of realized access. The customer is “in“ fire
system, now communication and image, managing fire moment of trufir
are utilized in actual utilization of services. Keeping fire promises
established by transactional marketing strategy is fire goal. Living up to fire
expectations set leads to positive experiences, improve or reinforced image
and posifive word-of-moufir communication.

The subjective indicators of realized access or amount of customer
satisfaction, are maintained or enhanced wifir relationship marketing, total
communication and image marketing, and managing fire moment of trufir.
The customer's perception of technical and especially functional quality of
fire service provided is imperative for expectations to be achieved and
maintenance of fire relationship. Increased customer satisfaction and
awareness leads to greater potential of utilization of services in the future

firus increasing access. The diagram which follows depict fire

A Marketing Plan 22

incorporation of fire marketing strategies discussed, wifirin fire health
access model increasing consumer awareness of fire role of fire nurse

practitioner in primary care and facilitating health care access.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transactional Health Policy I h
Marketing Financing Transactional
Traditional Organza' fion I rrrarketing;
Marketing \1 Identify service
Creafing N gpopulation
expectations I _J
by giving EotentialAccess
pronrises Structural Indicators: Process indicators: r W
team 4; emcee-m aster...
system ‘ population at risk 1 't ctive
I need, predspos‘ng/ strategy
enabling factors keeping
promises set by
V/ r transactional
NF B I l a K ReallzedAccks marketing
L___. Subjective indicators. Functional quality
life path Ohm ”cam -> customer satisfaction \ \1’ J
needs convenience QJ
image availability
role Provider characteristics n I
quality WSW
prevrous
experience
expected/experienced image

 

 

 

 

Relationship marketing

Gronroos' (1990) Marketing continuum depicting different strategies at

different point of access of Aday's 8 Anderson (1981) Health Access
Model. - Figure 3.

A Marketing Plan 23

The diagram above is divided demonstrating the use of transactional
or traditional markefing strategies on fire left of fire hashed line. The left
side of the model defines structural aspect i.e. Characteristics of fire
health care delivery system, types of service, purpose, availability, and
organizational aspect. it is here where fire expectations are created by
transactional markefing. (i.e. brochures, mass distributions, radio
advertising, etc.) The right side of fire model represent fire relationships
and interacfions of fire provider and fire customer. it is here where fire
promises set by transactional marketing are kept. Experienced quality
needs to equal or exceed expected quality in order to improve fire image of
fire provider in fire eyes of fire customer. Relationship or interactive
marketing strategies are utilized at point of actual access on fire right of
fire model to enhance word of moufir communication and increase
consumer awareness of the role of fire nurse practitioner.

odol

The current healfir care environment continues to revolve around fire
“illness model“ and fee for service provided. The literature states firat
consumers of healfir care services are dissatisfied with fire increasing cost
of health care and the inaccessibility of healfir care services (Pearson,
1993). Hogan 8 Hogan (1982) identified that fire acceptance of fire NP
role is contingent on experience with a nurse practitioner or knowledge of
fire nurse practitioner role. Role ambiguity and lack of consumer
knowledge are significant to NP practice. As stated earlier, fire literature

indicates fiiat firere is a potential market for NP services among healfir care

A Marketing Plan 24

consumers, however NPs must continue effort to inform consumers of
fireir services.

Traditionally, healfir consumers acquire knowledge of providers
firrough personal experience or advice from a friend or relative (Boofir 8
Babchuk, 1972). The absence of consumer information about price and
quality of medical services is fire most important difference between
medical care and nonhealfir goods and services. (Pauly, 1978).
inadequate consumer information has been cited as an important factor
contributing to “imperfections in the structure and fire conduct of the
market for healfir services.“ (Langwell 8 Moore, 1982, Sloan 8 Feldman,
197a). .

The development of a markefing plan needs to address fire
limitations discussed in fire literature of previous mefirods of
communication to consumers. The goals of market strategy will be to
provide information about fire role and service provided by fire NP and to
enhance word of moufir communication wifir positive provider/customer
interactions therefore increasing consumer awareness.

Elan

Transactional marketing strategies will be utilized to identify the
service or target populafion which can be accomplished by the following
strategies:

1. Utilizing community market research either independenfiy or
existing research which identifies community demographics, morbidity,

mortality, predisposing factors, enabling factors, and behavioral

A Marketing Plan 25

characteristics of fire population at risk. This type of research will provide
information concerning fire type of cliental which make up fire largest
population and of greatest need of services, which creates fire target
population.

2. A community needs assessment could also be completed
identifying the availability of services, type of services, purpose of services,
referrals needed, volume, distribution and organization of services. A
community assessment will also obtain information of services needed.
This research can be conducted by fire NP, obtained result from existing
community research, or conducted in collaboration wifir a markefing
consultant.

It is important to understand fire needs of a community prior to
marketing a service because it will be more difficult to convince fire
community firat your service is superior to fire service currenfiy being
provided. The act of convincing fire customer that a new service is
superior could also be viewed by existing providers as competition,
decreasing fire possibility of professional relationships wifir ofirer providers.
The new service being marketing needs to complement existing services
or provide needed service to fire community to be viewed as a benefit.

The target population of fire community is fire population assessed
as being fire most frequent users of the service or the population of greatest
need for fire service. It is important firat market strategies are congruent

with fire needs of fire target population for fire strategies to succeed.

A Marketing Plan 26

Relationship marketing or interactive strategies will also be utilized
in obtaining informafion specific to the community. Focus groups may be
utilized to obtain subjective information. This strategy will be utilized to
obtain fire communities perception of the services in existence, services
needed, and past experiences with different types of providers. The
community perception of provider image is important in marketing because
if provider image is unknown there is reluctance to utilize the service until
firere is a positive image established.

Transactional marketing is then utilized by creating expectations of
fire customers by giving promises. These promises are made based on fire
information obtained from community assessment and needs of fire target
population. The consumer is then informed by distribution of brochures,
newspaper advertisement, radio announcement, and mass distribution of
information via postal service.

The use of relationship marketing strategies for information
distribution is based on fire interactions with potential consumer groups.
This is accomplished by fire individual nurse practitioner, fire practice
manager, or in collaboration wifir a marketing consultant

1. Presentations at community group event communicating role of

provider and service. (i.e. PTA, Women's groups, Church

groups, Chamber of commerce groups)

2. Communication boofir at community healfir or business expos.

3. Community focus groups based on information distribution

4. Utilization of an affiliation wifir an established service provider.

A Marketing Plan 27

5. Establish relafionship with area Nurse Practitioners to
communicate role of provider and service

6. Utilize community liaisonor established community relationships
to educate fire role of provider, firis adds credibility.

7. Develop professional relationships wifir health care providers
wifir fire emphasis of cooperation, collaboration and increase in

accessibility of health care services.

Relationship marketing strategies are utilized further in fire actual
interactions between provider and client. Subjective indicators of realized
access such as patient satisfaction and quality are addressed. The goal of
relationship marketing is to keep fire promises set by transactional
marketing. If fire relationships are positive image is improved, creating a
positive word - of - mouth communication wifirin the community and
enhancing marketing.

Practice Setfing

Once in fire practice setting fire Nurse Practitioner ufilizes
relationship marketing and direct communication with fire client to enhance
positive image by:

- maintain “moment of trufir” keep fire promises established by

transactional marketing.

-ensure expected and experienced quality balance

-enhance word of moufir communications

The measurement of satisfaction and quality can be accomplished by:

A Marketing Plan 28

1. Patient satisfaction survey identifying criteria of quality, cost,

convenience, provider characteristics, and availability of service.

2. Follow up community focus groups obtaining information of

consumer perception of functional and technical quality of service.

Also to elicit information if marketing strategies increased consumer

awareness of fire service. Evaluation of marketing strategies is also

obtained to determine fire expected and the experienced quality of

fire interactions. This information may also be obtained firrough

questionnaires or community focus groups.
B E . l I |°

Implementation of fire marketing plan begins wifir fire assessment of
fire community. The assessment determines what is the communities
knowledge of the NP role, what services are currenfiy provided, what
services are lacking, what is the community perception of healfir care, what
are fire community demographics, and who are fire population at risk?
This data obtained from fire community assessment is fire basis for fire
development and implementation of the plan as firis assist fire provider to
market fire service to fire target population. Once fire target population has
'been established, focus groups wifir randomly selected members of the
target population are held to determine image of provider, knowledge of
different providers, perceptions of existing services, and perceptions of
needed services.

information is distributed by transactional marketing strategies, thus

creating fire consumer expectations. This is accomplished by fire following

A Marketing Plan 29

types of communication:

1. Personal Communication. This type of communication is not part of fire
actual production or consumption of fire service. This type would involve
fire regulatory boards description of fire NP role. The NPs working in fire
field need to become more active in the Professions lobby to reform
legislation; mainly prescriptive authority, reimbursement, and legal scope of
practice, for standardization of independent scope of practice, prescriptive
aufirority, and reimbursement before fire consumer will view fire profession
as creditable and competent. Care needs to be taken to ensure firat what
fire profession promises can be delivered to fire customer to reduce
possibility of a gap in expected and experienced quality.

2. W This type of communication is impersonal but
can reach a large population. Advertising brochures and mass distribution
of information defining fire NP role, supported by study result describing
technical quality, are distributed to raise knowledge and awareness of fire
NP role. Physician pracfices employing NPs could distribute brochures
describing fireir collaborative practice wifir NPs and advocating physician
support of the NP role.

3. Direct @mmunigation This type of communication is personalized
communications directed toward potential customers. Target populations
are identified by research of potential users of fire service, and advertising
campaigns and brochures directed toward fire target population. Care is

taken to delineate fire role and the type of service is consistent with

A Marketing Plan 30

identified societal need, firat service providers are of same or reduced cost
as existing service, and the service is consistent wifir existing norms.
4. Integcfive communicatign. Types of interactive communication would
involve focus groups within fire community to educate fire community's
perception of fire NP role and gather information via customer feed back
loop to identify further area for potential education. Relationship marketing
strategies utilizing interactive communication, to ensure
expected/experienced quality balance. The goal of relafionship marketing
is to keep the promises set by transactional marketing. lf fire relationships
are positive, image is improved, and creates a positive word - of - mouth
communication wifirin the community that enhances marketing.

Practice Setting -

Once in the practice setting the Nurse Practitioner utilizes
relationship marketing and direct communication with fire client to enhance
positive image by:

- maintain ”moment of truth” keep the promises established by

transactional markefing.

-ensure expected and experienced quality balance

-enhance word of moufir communications.

Wilma

Evaluation of the marketing plan involves obtaining information from
fire consumer to determine fire effectiveness of marketing strategies. This
process involves the development of a questionnaire to obtain information

of how consumer was informed of fire service. To furfirer evaluate the

A Marketing Plan 31

service satisfaction and quality information can be obtained utilizing a
satisfaction survey to determine expected and experienced quality of
service. The measurement of satisfaction and quality can be accomplished
by:
1. Patient satisfaction survey identifying criteria of quality, cost,
convenience, provider characteristics, and availability of service.
These surveys are distributed to consumers who have utilized fire
service.
2. Follow up community focus groups obtaining information of
consumer perception of functional and technical quality of service.
3. Distribution of questionnaires to fire community focusing on
obtaining data of the consumers knowledge of NP service after
marketing strategies have taken place. Did fire strategies work?
What information does the community have now?
4. Evaluation of marketing strategies focuses on fire impact the
strategies had on increasing ufilizafion of fire NP services. This
utilization can be measured by:
- tracking the number of new client into the practice
- tracking the number of referrals received into the practice by
other health care providers.
- Tracking fire number of client in fire caseload in 6 months,
12 months, 18 months.

- Tracking the number of return client visits.

A Marketing Plan 32

- Tracking fire number of services reimbursed directly under
fire NP provider number.
I li one or Advanced N rsi Practice

Consumer awareness of fire role of fire nurse practitioner has been
shown to be a significant barrier to NP practice. Individual nurse
practitioners emphasis on informing consumers of the healfir care role that
NPs can provide is crucial to break down firis barrier.

This can be accomplished by:

1. Nurse practitioners can have an impact on barriers to fireir
practice by becoming involved wifirin fire community. Involvement
increases fire provider visibility and provides consumers with information.

- Conducting presentations at community group event

communicating role of provider and service. (i.e. PTA, Women's

groups, church groups, Chamber of commerce groups).

- The NP can utilize communication booth at community health or

business expos.

- The NP can conduct community focus groups based on

inforrrration distribution.

- Develop and distribute brochures to introduce fire NP role by direct

and mass distribution.

- Utiiize a community liaison or a pre 'iousiy established community

relationship to assist in accessing community event. as. schools,

parent association, community education group, sport league.) An

A Marketing Plan 33

established relationship will add personal credibility even if there is

limited knowledge of fire service.

2. Develop professional relationships with health care providers
with fire emphasis of cooperation, collaboration and increase in
accessibility of health services. Working in a collaborative relationship with
ofirer healfir care providers also establishes credibility of the NP and
support a positive image of the role. Development of a professional
relationship includes:

- Obtaining privileges at local health care facilities 03. hospitals,

extended care facilities, rehab facilities).

- Attend medical staff or committee meetings of firose facilities.

- Volunteer for committee or task force membership for joint practice

issues.

- Establish a peer review group

- Obtaining a preferred provider number for direct billing and

reimbursement purposes.

3. Utilize an affiliation with an established service provider to
communicate fire NP role as in a collaborative practice agreement.

- Send letters to fire clients in the practice introducing them to fire

NP service.

- Develop and distribute brochure describing fire role of fire NP and

the service provided. .

- Send letters to area providers the NP may utilize as a consultant

along with client referrals.

A Marketing Plan 34

- Acknowledge referrals from ofirer health care professionals wifir a

letter thanking firem for fire referral.

4. Establish relationship wifir area NPs to communicate role of fire
provider and service provided. It is also important to network with other
NPs to communicate fire same message to fire community to reduce role
ambiguity.

- Develop peer support group with area NPs.

- Attend local and national continuing education conferences

- Professional networking within the NP professional organization
Professional networking within professional organizations is important to
ensure consistency of fire professional message that is being sent to fire
consumer. Involvement in fire professional lobby remains key to delineate
fire nafional role of the nurse practitioner there by reducing role ambiguity.
Involvement within fire professional lobby to reform practice issues such as
reimbursement and prescriptive authority remains important to add
credibility to the NP role.

Increasing consumer awareness of the role of fire NP would have a
positive impact on legislative reform as it is fire consumer who will be
deciding what type of care they want. If the consumer is satisfied with fire
quality of NP services firis will be communicated to legislators to reform
reimbursement, prescriptive authority, and legal scope of practice barriers.
B l I. E I I.

Recommendafions for education continue with fire NP responsibility

to inform client and other healfir care providers of fire role of the NP.

A Marketing Plan 35

Utilization of this comprehensive marketing plan increases fire flow of
information necessary to assist fire consumer to form a level of knowledge
required to make informed choices about healfir care services. Increasing
consumer awareness of fire role of fire NP in primary care allows fire
consumer additional choices in healfir care there by improving access and
distribution of health care.

Nurse Practitioners can continue to affiliate with colleges and
universities and remain active in nursing education. By presenting actual
experiences, the NP can educate nursing student in the importance of
developing marketing strategies to communicate to fire co9mmunity the
role of nursing.

WED

The literature on health care marketing mainly focuses on fire
structural aspect of marketing. There is limited research on fire process or
relationship marketing as it relates to consumer awareness. Inadequate
consumer information has been cited as an important factor contributing to
“imperfections in the structure and fire conduct of the market for health
services“ (Langwell 8 Moore, 1982, Sloan 8 Feldman, 1978).
Recommendations for further research are suggested in quantitative
studies focusing on fire relationship between increasing awareness of
services and consumer access and studies focusing on communication,

positive word of moufir, and image in relationship to utilization of services.

A Marketing Plan 36

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