A case study of the nurse practitioner consultation in primary care: communication processes and social interactions

Background:
Nurse practitioners are increasingly conducting consultations withpatients on the same basis as medical doctors. However little is known aboutcommunication within nurse practitioner consultations. Research on communicationin nurse practitioner consultations has identified nurse practitioners communicatewith patients in a hybrid style, combining biomedical information with the discussionof subjective information from everyday life. Research has not fully explained whythis hybrid style occurs in nurse practitioner consultations, nor determined its links toconsultation duration, patient expectations, satisfaction, and enablement. This studywas developed to address these gaps in research of communication in nursepractitioner consultations.

Aim:
This study aims to advance understanding of the discrete nature of thecommunication processes and social interactions occurring in the nurse practitionerconsultation, including explicating the reasons for the occurrence of the particularcommunication processes and interaction styles observed in those consultations.

Methods:
The study was conducted in a nurse-led primary care clinic providinggeneral practice care. Within a case study research approach mixed methods wereutilised, combining structured analysis of video recorded observations of nursepractitioner consultations, questionnaire-based measures of patient expectations,satisfaction, and enablement, and interviews with some of the participants of theconsultations. The sample for video recording comprised three nurse practitionersemployed at the clinic, and 30 patients registered at the clinic. Questionnaireresponses were provided by 71 patients, including 26 whose consultations had beenvideo recorded. All three nurse practitioners participated in post-consultationindividual interviews, and 11 patient / carers participated in post-consultationindividual interviews. The video recorded consultations were analysed with the RoterInteraction Analysis System (RIAS), a method of quantified interactions frequencyanalysis. The questionnaire responses were analysed with descriptive statistics.Transcripts of the interviews were analysed using computerised qualitative dataanalysis with NVivo.

Findings:
A significant majority of observed social interaction in the consultationsused patient-centred communication styles (p=0.005), with neither nursepractitioners nor patients or carers being significantly more verbally dominant. Nurseiipractitioners guided the sequence of consultation interaction phases, but patientsand carers participated through asking questions and involvement in negotiations forcare planning. Patient / carers were highly satisfied with their consultations, andsignificantly higher general satisfaction was noted when participants expected thenurse practitioners to be able to diagnose their presenting problem (p=0.043).Patient / carers expressed significantly higher levels of enablement than have beenseen in previous studies of enablement with other types of clinicians (p=0.003). Themean consultation time length of 10.97 minutes is comparable with studies ofgeneral practitioners. The participants’ perceptions of nurse practitioner consultationcommunication processes and social interactions were represented through sixthemes; Consulting style of nurse practitioners; Nurse practitioner – GPcomparisons; Lifeworld content or lifeworld style issues; Nurse practitioner roleambiguity; Creating the impression of time; and Expectations for safety netting.

Contribution to knowledge:
This study reveals nurse practitioner consultationscomprise collaborative openness to peoples’ agendas and questions, expressions ofeveryday lifeworld experiences, expanded impressions of time, clear explanationsaugmented by integrated clinical reasoning, and participatory negotiations. Thesecommunicative features arise from a combination of social, ideological, andepistemological factors, prompting nurse practitioners to privilege how they interactwith patients and carers, and to adopt a hybrid patient-centred style combining thenursing ideology of holism and their knowledge of biomedicine. This form ofcommunication has been characterised as a stylistic exemplar for good consultationcommunication practice, which potentially facilitates shared decision-making. Thisresearch has resulted in new knowledge of the communication processes and socialinteractions used in nurse practitioner consultations, which demonstrates theimportance of clinicians giving precedence to how they communicate and interactwith patients so as to optimise their therapeutic outcomes without compromising theduration of consultations.