A study comparing the consultation practice of Advanced

A study comparing the consultation practice of Advanced Nurse Practitioners and General Practitioners in Primary Care Dr Hilary Paniagua

Aims • To find out what ANPs do • What is advanced practice

Design of the study • ANPs and GPs worked together doing the same roles • Training practice within an urban general practice • in the West Midlands Emergency surgeries of 2 ANPs with MSc in Advanced Practice and 2 GPs

Chosen methodology • Capture natural occurring talk by video recording • • GP and ANP emergency consultations Structuralist and poststructuralist linguistic philosophy that are access to reality is through language. Words are considered to be how individuals experience themselves and others within the world, and how these experiences are interpreted

Sequential Stages of the Consultation Process Similarities with GPs Differences with GPs The Opening Stage • Both used the same medical expressions and greetings, asking ‘what can I do for you? ’ This stage was no different to that of GPs The History-taking Stage • The medical pattern of history taking was the same • • • Patient interactions s were more informal. ANPs allowed patients to interrupt them, to chat and on occasions listen to long patient stories. Because of this history gathering was both medical and holistic The Physical Examination Stage • • • Both practitioners initiated medical expressions of asking ‘to look at’ patients to initiate examinations, despite undertaking more than ‘looking’. Medical techniques and examination skills were the same. Rather than to confirm a diagnosis, both practitioners examined to verify normality. • • Patients interacted more and were more actively involved in the examination process. Nursing skills facilitated the incorporation of patient opinion and true partnership. The Diagnostic Stage • • Both made a diagnosis • ANPs were either tentative about providing diagnostic statements or did not do it at all. On occasions it was the patient who provided the verbal diagnosis. The Management Stage • Medical treatment was the same for identified conditions. • • • ANPs based their management mostly from an undeclared medical diagnosis. Patient relationship with was different, patients were more interactive and they even changed the decisions ANPs made. Patient choice was always included and evidence existed of equipoise where true options existed; unlike GPs there was no sense of the nurse's dominance or manipulation over the patient. The Closing Stage • Both practitioners initiated the same pre closure medical expressions making arrangements for patient to 'come back' if necessary. This stage was no different to that of GPs.

001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 Transcript D 2. 3 Consultation with GP and elderly patient with angina P 3: look I (2. 0) can’t get me breath when I start walking DA: right (patient prods at his chest) P 3: and the (2. 0) I have to be walking (1. 0) pains DA: ou’re getting pains you’re y P 3: yeah DA: when you’re walking are [you P 3: [it’s not a pain its tightness = DA: = right = P 3: right DA: how long has that been going on [ for now? P 3: [it’s gradually come on for about the last three P 3 weeks it’s just getting worse and worse like DA: ok P 3: yeah DA: are you breathless every time you’re walking P 3: yeah I am DA: or is it just in [certain conditions P 3 [no I am now [like when I first started it was just (2) I walked yer DA: [ok P 3: know cos I walk quite a bit like (1) I’ve had a bypass DA: [right P 3: [as I walk[ DA [now (2) have you had angina pain before (1) given

001 P 2 002 Su: 003 P 2: 004 Su: 005 P 2: 006 P 2: 007 P 2: 008 Su: 009 P 2: 010 P 2: 011 Su: 012 P 2: 013 P 2: 014 Su: 015 P 2: 016 Su: 017 Su: 018 Su: 019 P 2: 020 Su: 021 P 2: 022 Su: 023 P 2: 024 P 2: 025 Su: 026 P 2: 027 P 2: 028 Su: 029 Su: 030 P 2: 031 P 2: 032 Su: 033 P 2: 034 P 2: 035 P 2: 036 P 2: 037 P 2: 038 P 2: 039 P 2: Transcript A 2. 1 -2 Consultation with ANP and patient who wants to talk I can’t really say you’re going to help me but I wanted to talk to you about it = = that’s fine= = I haven’t sort of felt right for weeks you know [ just sort feel its not going [mumm away this ache and this feeling that I’ve got I’m not just right and I felt my arms kind of itching now today I haven’t felt it but everyday I’m scratching at my arms the back of my neck remember when I had that bad fall on the a bus remember at X = = yes = = now they said I had a crack ah crack in my head and I had a break in my collar bone yes that’s right = = now honestly sometimes when I turn my head and I’ve got my hair looks like up the back so often will it wear off that’s what I wanted to say how long ago now was that? it’s about seven months [eight months ago[ June it was [yeah [mumm I wonder if you’ve got perhaps a little bit of arthritis in the back of your neck as well perhaps it’s exaggerated it a little bit = = oh do you think so? don’t know we’ll have a look at you so well that’s a (. )[ [now when did the irritation start = = it’s just itching I feel like scratching my neck to sometime and this arm mind you did I tell you about three weeks ago I had a a car knocked me down ohh dear = = everything happens at once but all my life I’ve never had anything up until two years ago and I’ve three things [one after the other in two years [mumm and how did your road traffic accident happen well I was crossing the road, not at the crossing needless to say, but you know going along X road to X, [ lights were stopped at X road, [so I knew there was nothing coming at the next [mumm stop after that the crossing, the stop, so the next car I could see was way past the school there, you know, and it was belting along. I tho I’ll make that easy cos I’m quite a quick walker you know, and I was about that much off the pavement, now this is, that’s the truth, about that much off the pavement, he says he didn’t see me can you imagine? I was crossing the road, no no traffic coming that way and he said he didn’t see me, and I said well you shouldn’t be driving if you didn’t see me, well anyhow to cut a long story short, he he swerved he put his brakes on he swerved to the centre, well of course the next car coming (leans fast forward) 040 P 2: along so fast he came at me, the next car came at me you know and knocked me and I sort of 041 P 2: myself lying just like exactly like I’ve shown you (11 lines missing about GP) 053 P 2: after that I just wanted to talk to you about it what do you think 054 Su: um I’m sure he’s right may I have a little look at you shall I? (consultation proceeds to a full examination)

ANPs had a different relationship with patients • Patients interacted more with ANPs because: a) ANPs worked to diminish social distance with patients b) Patients were always aware of what nurses were thinking and why they did things as they used online thinking (voice of nursing) c) ANPs worked within a medical framework yet interweaved their nursing skills within this (medico-nursing world)

The medico-nursing world/the ‘voice of nursing’ 150 Sz: I’ll just get you some a leaflet (2. 0) there are different 151 types of worms but the most common is the little tiny thread worm[ which 152 M: [right ANP turns to face mother 153 Sz: is what you they um (1) I’ve got twins and um when the one of them was 154 six months old she actually passed a round worm which is like a white 155 earth worm and the only way she’d have picked that up was from dogs or 156 and we didn’t have any so I don’t know whether the previous owners of the 157 house had a dog and she’d been crawling in the garden and I mean I nearly 158 died because this thing was [like six inches long and even though I’m medical 159 M: [ohh no 160 Sz I’d never seen something so I couldn’t quite work out what 161 M oh no and the fact it was coming from your own child you see 162 Sz: um

ANPs used the strategy of thinking aloud and ‘on-line’ 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 Su: ok um what could we put (. ) it’s such a difficult spot isn’t it right on your eyelid = P 2: = yes Su: normally I say use a bit of hydrocortisone which you can if you are extremely careful = P 2: = yeah Su: um if Claritin normally works that’s fine we could change your antihistamines = P 2: = um = Su: = and try something different P 2: well I had some Zertec on holiday cos I had a reaction to my suntan lotion = Su: = it’s an odd set up right P 2: but it I don’t know whether it was but I taking I took the first one at about 11 o’clock when P 2: I started [to itch with this rash and then by about 4 o’clock I was zonked and they made me feel Su: [yes P 2: a bit sick Su: right so so stick to the Claritin then

No verbal diagnosis 091 092 093 094 095 096 097 Sz: P 2: I can’t um find anything dramatic on your chest no oh that’s something um and it’s one of those situations where isn’t it? where I am sure if you leave it long enough it would go away of its own accord = = yeah = but the fact that you’re feeling a bit tight yeah (tilts head backwards and strokes throat) 098 Sz: it may very well be that at night that because your nose is blocked when you lie down it drips to 099 Sz: the back of your throat[ 100 P 2: [mum[ (makes a sweeping motion with both arms upwards backwards and forwards) 101 Sz: [rather than actually it being a chest infection but I can see 102 Sz: from the type of person that you’re not a great attender 103 P 2: no (14 lines ANP checking the infrequent history of visits) 117 Sz: yeah no so I am quite happy to give you a week’s supply of an antibiotic because of that 118 P 2: thank you very much

Ideas on Advanced Practice • Involves the response created with patients • Creating partnerships • Seen in the voice of nursing • Is the creation of a medic-nursing world • Involves strategies such as online thinking

THANK YOU!