Patients' perceptions of ߢuncertainty' in nurse practitioner consultations

Nurse practitioner consultations in primary health care: patient, carer, and nurse practitioner qualitative interpretations of communication processes

Aim

To advance understanding of the discrete nature of the communication processes and social interactions occurring in nurse practitioner consultations.

Background

Preceding qualitative investigations of nurse practitioner consultations have, when conducting interviews with participants, often exclusively sampled either nurse practitioners or patients. Furthermore, previous qualitative studies of the nature of nurse practitioner consultations have not typically also sampled carers attending with patients for nurse practitioner consultations. Accordingly this study was developed, in part, to address this exclusivity of sampling in qualitative research of nurse practitioner consultations by developing an inclusive sample of patient, carer and nurse practitioner participants of nurse practitioner consultations, so as to conjointly develop an understanding of the multiple perceptions of those participants of communication processes occurring in nurse practitioner consultations.

Methods

Qualitative component of a larger mixed methods case study of communication processes and social interactions in nurse practitioner consultations, utilising individual semi-structured interviews with the patient (n = 9), carer (n = 2) and nurse practitioner (n = 3) participants of video-recorded consultations derived from a nurse practitioner-led general practice clinic. Interview transcripts were initially analysed via an emergent thematic analysis, followed up by computer-assisted qualitative data analysis with NVivo 9.

Findings

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; Nurse practitioner role ambiguity; Creating the impression of time and Expectations for safety netting. The findings identify a need for policy makers to address a perceived ambiguity of the nature of the nurse practitioner role amongst patients and carers. The benefits of nurse practitioners using personable, everyday lifeworld styles of communication for optimising interactions, sharing clinical reasoning and conveying a sense of having time for patients and carers in consultations are also identified.

Nurse practitioner consultations in primary health care: a case study-based survey of patients' pre-consultation expectations, and post-consultation satisfaction and enablement

Background

Research has not yet fully investigated links to consultation duration, patient expectations, satisfaction, and enablement in nurse practitioner consultations. This study was developed to address some of these research gaps in nurse practitioner consultations, particularly with a focus on expectations, satisfaction, and enablement.

Aim

To explore the influence of pre-consultation expectations, and consultation time length durations on patient satisfaction and enablement in nurse practitioner consultations in primary health care.

Design

Survey component of a larger convergent parallel mixed methods case study designed to conjointly investigate the communication processes, social interactions, and measured outcomes of nurse practitioner consultations. The survey element of the case study focusses on investigating patients’ pre-consultation expectations and post-consultation patient satisfaction and enablement.

Methods

A questionnaire measuring pre-consultation expectations, and post-consultation satisfaction and enablement, completed by a convenience sample of 71 adults consulting with nurse practitioners at a general practice clinic. Initial fieldwork took place in September 2011 to November 2012, with subsequent follow-up fieldwork in October 2016.

Results

Respondents were highly satisfied with their consultations and expressed significantly higher levels of enablement than have been seen in previous studies of enablement with other types of clinicians (P=0.003). A significant, small to moderate, positive correlation of 0.427 (P=0.005) between general satisfaction and enablement was noted. No significant correlation was seen between consultation time lengths and satisfaction or enablement.

Conclusion

Higher levels of patient enablement and satisfaction are not necessarily determined by the time lengths of consultations, and how consultations are conducted may be more important than their time lengths for optimising patient satisfaction and enablement.

A program of nurse algorithm-guided care for adult patients with acute minor illnesses in primary care

Background

Attention to patients with acute minor-illnesses requesting same-day consultation represents a major burden in primary care. The workload is assumed by general practitioners in many countries. A number of reports suggest that care to these patients may be provided, at in least in part, by nurses. However, there is scarce information with respect to the applicability of a program of nurse management for adult patients with acute minor-illnesses in large areas. The aim of this study is to assess the effectiveness of a program of nurse algorithm-guided care for adult patients with acute minor illnesses requesting same-day consultation in primary care in a largely populated area.

Methods

A cross-sectional study of all adult patients seeking same day consultation for 16 common acute minor illnesses in a large geographical area with 284 primary care practices. Patients were included in a program of nurse case management using management algorithms. The main outcome measure was case resolution, defined as completion of the algorithm by the nurse without need of referral of the patient to the general practitioner. The secondary outcome measure was return to consultation, defined as requirement of new consultation for the same reason as the first one, in primary care within a 7-day period.

Results

During a two year period (April 2009-April 2011), a total of 1,209,669 consultations were performed in the program. Case resolution was achieved by nurses in 62.5% of consultations. The remaining cases were referred to a general practitioner. Resolution rates ranged from 94.2% in patients with burns to 42% in patients with upper respiratory symptoms. None of the 16 minor illnesses had a resolution rate below 40%. Return to consultation during a 7-day period was low, only 4.6%.

Conclusions

A program of algorithms-guided care is effective for nurse case management of patients requesting same day consultation for minor illnesses in primary care.

Do epilepsy specialist nurses use a similar history-taking process as consultant neurologists in the differential diagnosis of patients presenting with a first seizure?

The development of specialist nursing practice has blurred the boundaries between medicine and nursing. This mainly qualitative study compares the structure of epilepsy specialist nurse (ESN) and consultant neurologist (CN) clinical interviews at first seizure presentation and opinion on diagnosis. Twenty patients with a suspected first seizure were randomly allocated for clinical review with an ESN and then a CN, or vice versa. Clinical interviews were unstructured and audio-recorded. The ESN and CN reached an independent diagnosis for each patient. Audiotapes were transcribed verbatim. Emergent themes were identified, catalogued and grouped into major thematic areas. Annotated audio recordings, medical notes and dictated clinic letters were used to validate findings. Statistical analysis of inter-rater agreement of diagnosis was evaluated using Kappa. The clinical interviews of CN and ESN were similar in structure. Differences demonstrated CNs concentrated on the prodrome to events and expressed less diagnostic uncertainty. ESNs concentrated on post-ictal recovery and used more investigations. Complete disagreement on diagnosis occurred in 5 (25%) patients. Kappa score=0.510, demonstrating a moderate level of inter rater agreement on diagnosis between the CN and ESN.

Who determines the patient mix of GP trainees? The role of the receptionist

BACKGROUND

During their specialty training, Dutch GP trainees work at a GP under the supervision of a GP trainer. Research suggests that the patient mix of GP trainees differs from that of their trainers. Receptionists assign patients to either the trainee or the trainer, thereby influencing the patient mix of the trainees. The decision to which doctor to assign is complex and depends on the latitude the receptionists have. Their considerations when assigning patients are unknown.

OBJECTIVE

To study receptionists' assigning behaviour.

METHODS

This was a questionnaire survey. To design the questionnaire, topics about assigning behaviour were identified in a focus group. The resulting questionnaire was sent to 478 GP training practices in the Netherlands.

RESULTS

Response rate was 68%. Of the receptionists, 95% asked for the reason for the consultation at least 'sometimes'. Most (86.3%) of the receptionists considered the patient mix of trainees and trainers to be similar. Almost all receptionists (97%) reported 'often' or 'always' assigning 'every possible problem' to the trainee and a similar picture arose regarding specific subpopulations. However, the receptionists reported that they assigned complex and new patients to the trainers more often than to trainees.

CONCLUSION

With some exceptions, receptionists try to assign trainees a varied patient mix.

Benefits and limitations of nurses taking on aspects of the clinical role of doctors in primary care: integrative literature review

AIM

This paper presents an integrative literature review of studies exploring the benefits and limitations of the recent expansion of the clinical role of nurses working in general practice in the United Kingdom.

BACKGROUND

Similar clinical outcomes and high levels of satisfaction with consultations undertaken by nurse practitioners compared to general practitioners in primary care have been reported in a Cochrane review [Cochrane Database of Systematic Reviews (2004) vol. 5, p. CD001271]. Since then, nurse consultations have increased considerably as general practitioners have delegated part of their clinical workload to other general practice nurses. However, whether all general practice nurses can fulfil this extended role remains open to question.

METHOD

An integrative review was performed. Nine electronic databases were searched. UK studies were included if they were published after the previous Cochrane review, i.e. between 2004 and 2009.

RESULTS

Eight studies were identified, most using qualitative methodology. The evidence suggested that the changes in nurses' role have been predominantly driven by the perceived increase in workload arising from the new general practitioner contract. Delegating work to nurses provided a means of organizing workload within a practice without necessarily allowing patient choice. Patients generally thought that all general practice nurses would be able to deal with simple conditions, but they would prefer to consult with a general practitioner if they thought it necessary. There were concerns about nurses' knowledge base, particularly in diagnostics and therapeutics, and their levels of training and competence in roles formerly undertaken by general practitioners.

CONCLUSION

There have been few studies in this key area of healthcare policy. There is a need for better training and support for nurses undertaking roles in consultation and for patients' views to be better represented.