A case study of the nurse practitioner consultation in primary care:  communication processes and social interactions
Creators: name: Barratt, J
Publisher: name: London South Bank University
Year: 2016

description: Background: Nurse practitioners are increasingly conducting consultations with
patients on the same basis as medical doctors. However little is known about
communication within nurse practitioner consultations. Research on communication
in nurse practitioner consultations has identified nurse practitioners communicate
with patients in a hybrid style, combining biomedical information with the discussion
of subjective information from everyday life. Research has not fully explained why
this hybrid style occurs in nurse practitioner consultations, nor determined its links to
consultation duration, patient expectations, satisfaction, and enablement. This study
was developed to address these gaps in research of communication in nurse
practitioner consultations.
Aim: This study aims to advance understanding of the discrete nature of the
communication processes and social interactions occurring in the nurse practitioner
consultation, including explicating the reasons for the occurrence of the particular
communication processes and interaction styles observed in those consultations.
Methods: The study was conducted in a nurse-led primary care clinic providing
general practice care. Within a case study research approach mixed methods were
utilised, combining structured analysis of video recorded observations of nurse
practitioner consultations, questionnaire-based measures of patient expectations,
satisfaction, and enablement, and interviews with some of the participants of the
consultations. The sample for video recording comprised three nurse practitioners
employed at the clinic, and 30 patients registered at the clinic. Questionnaire
responses were provided by 71 patients, including 26 whose consultations had been
video recorded. All three nurse practitioners participated in post-consultation
individual interviews, and 11 patient / carers participated in post-consultation
individual interviews. The video recorded consultations were analysed with the Roter
Interaction Analysis System (RIAS), a method of quantified interactions frequency
analysis. The questionnaire responses were analysed with descriptive statistics.
Transcripts of the interviews were analysed using computerised qualitative data
analysis with NVivo.
Findings: A significant majority of observed social interaction in the consultations
used patient-centred communication styles (p=0.005), with neither nurse
practitioners nor patients or carers being significantly more verbally dominant. Nurse
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practitioners guided the sequence of consultation interaction phases, but patients
and carers participated through asking questions and involvement in negotiations for
care planning. Patient / carers were highly satisfied with their consultations, and
significantly higher general satisfaction was noted when participants expected the
nurse practitioners to be able to diagnose their presenting problem (p=0.043).
Patient / carers expressed significantly higher levels of enablement than have been
seen in previous studies of enablement with other types of clinicians (p=0.003). The
mean consultation time length of 10.97 minutes is comparable with studies of
general practitioners. The participants’ perceptions of nurse practitioner consultation
communication processes and social interactions were represented through six
themes; Consulting style of nurse practitioners; Nurse practitioner – GP
comparisons; Lifeworld content or lifeworld style issues; Nurse practitioner role
ambiguity; Creating the impression of time; and Expectations for safety netting.
Contribution to knowledge: This study reveals nurse practitioner consultations
comprise collaborative openness to peoples’ agendas and questions, expressions of
everyday lifeworld experiences, expanded impressions of time, clear explanations
augmented by integrated clinical reasoning, and participatory negotiations. These
communicative features arise from a combination of social, ideological, and
epistemological factors, prompting nurse practitioners to privilege how they interact
with patients and carers, and to adopt a hybrid patient-centred style combining the
nursing ideology of holism and their knowledge of biomedicine. This form of
communication has been characterised as a stylistic exemplar for good consultation
communication practice, which potentially facilitates shared decision-making. This
research has resulted in new knowledge of the communication processes and social
interactions used in nurse practitioner consultations, which demonstrates the
importance of clinicians giving precedence to how they communicate and interact
with patients so as to optimise their therapeutic outcomes without compromising the
duration of consultations.