Nurse Practitioner Consultations Research Articles

A novel pathway for insurance-based breast reductions: A method for identifying appropriate surgical candidates

Breast reductions are one of the most common plastic surgery procedures performed. The purpose of this study was to streamline the evaluation of patients requiring breast reduction by using a nurse practitioner (NP)-led class to funnel appropriate surgical candidates through the preoperative process. We performed a retrospective review of patients interested in breast reduction who enrolled in this class from March 2015 to August 2021. Of the 1310 unique patients enrolled in the initial class, 386 patients passed the initial screening and were scheduled with the NP, whereas 924 were screened out at this stage either for being an inadequate surgical candidate or not showing up for clinical visits (36.7%). An additional 185 were screened out after the consultation with NP for reasons such as lack of insurance coverage and no-show visits (20.2%). MD visits had a no-show rate of 7.08%. The decrease in no-show rates between the class-NP visit and the NP-MD visit were both significant (p < 0.001). There was no significant difference in gram estimates between providers and pathology (p = 0.5). In total, 171 patients underwent breast reduction (13.05% of the patients screened). The average time from class to surgery was 278.15 days, NP consultation to surgery was 171.48 days, and MD consultation to surgery was 59.51 days. Using a screening pathway allows for early identification of inadequate surgical candidates and therefore streamlines the screening process for optimized breast reduction candidates. Appropriate use of NP visits functions to streamline the funnel, thus decreasing the number of visits and no-show appointments for a surgeon.

Patient perceived needs and experiences of person-centered care in patients with inflammatory arthritis.

Health care is shifting toward a person-centered care (PCC) approach. For implementation of PCC, there may be a special role for nurse practitioners (NPs). The aim of this study was to explore the patient-perceived levels of and needs for of PCC in inflammatory arthritis patients who visited the NP at the outpatient clinic of an academic hospital in the Netherlands. A cross-sectional study was performed. Disease characteristics were inventoried from the patient records. Patients filled out the PCCoc/rheum instrument, an instrument to measure patient perceived PCC, and a questionnaire based on the 14 life areas of the Self-Management Web, extended with areas including pain, fatigue, and night's rest. Participants were asked which life areas caused problems, and whether these problems were discussed. Mean values were calculated for normally distributed data and medians for nonnormally distributed data. Most of the patients had well-controlled disease (86.1%). The mean score of the PCCoc/rheum was 55.3 (SD 8.1). Patients experienced most problems in life areas fatigue (37.3%) and pain (35.3%), these were also the life areas that were most often addressed at consultation. The life areas that gave problems and that were least addressed during consultation were intimate relationships & sexuality (66.7%) and household chores (58.8%). Despite an overall high level of patient perceived PCC delivered by NPs, patient with low disease activity frequently reported problems in life areas not addressed at consultation. Implementation of the Self-Management Web and changing the focus of NP consultations may help to improve accommodating individual patient needs.

Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study

BackgroundPrimary care systems around the world have implemented nurse practitioners (NPs) to ensure access to high quality care in times of general practitioner (GP) shortages and changing health care needs of a multimorbid, ageing population. In Switzerland, NPs are currently being introduced, and their exact role is yet to be determined. The aim of this study was to get insight into patient characteristics and services provided in NP consultations compared to GP consultations in Swiss primary care.MethodsThis case study used retrospective observational data from electronic medical records of a family practice with one NP and two GPs. Data on patient-provider encounters were collected between August 2017 and December 2018. We used logistic regression to assess associations between the assignment of the patients to the NP or GP and patient characteristics and delivered services respectively.ResultsData from 5210 patients participating in 27,811 consultations were analyzed. The average patient age was 44.3 years (SD 22.6), 47.1% of the patients were female and 19.4% multimorbid. 1613 (5.8%) consultations were with the NP, and 26,198 (94.2%) with the two GPs. Patients in NP consultations were more often aged 85+ (OR 3.43; 95%-CI 2.70–4.36), multimorbid (OR 1.37; 95%-CI 1.24–1.51; p < 0.001) and polypharmaceutical (OR 1.28; 95%-CI 1.15–1.42; p < 0.001) in comparison to GP consultations. In NP consultations, vital signs (OR 3.05; 95%-CI 2.72–3.42; p < 0.001) and anthropometric data (OR 1.33; 95%-CI 1.09–1.63; p 0.005) were measured more frequently, and lab tests (OR 1.16; 95%-CI 1.04–1.30; p 0.008) were ordered more often compared to GP consultations, independent of patient characteristics. By contrast, medications (OR 0.35; 95%-CI 0.30–0.41; p < 0.001) were prescribed or changed less frequently in NP consultations.ConclusionsQuantitative data from pilot projects provide valuable insights into NP tasks and activities in Swiss primary care. Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.

Nurse Practitioners in Swiss Family Practices as Potentially Autonomous Providers of Home Visits: An Exploratory Study of Two Cases

In Swiss primary care, general practitioner (GP) home visits have decreased due to impending GP shortages particularly in rural areas. Nurse practitioners (NP) are newly introduced in family practices and could potentially offer home visits to the increasing number of multimorbid elderly. We analysed consultation data from two pilot projects (Practice A and Practice B) with the goal to measure the frequency and patient characteristics of NP consultations both in the practice and on home visits, and to determine the NPs’ autonomy based on the required GP supervision. In Practice A, 17% of all NP consultations were home visits, in Practice B 51%. In both practices, the NPs saw older patients and reported higher autonomy on home visits compared to consultations in the practice. In Practice A, the NP encountered a higher share of multimorbid patients on home visits than in the practice, and the NP’s proportion of autonomously conducted consultations increased from 0% in the first month to 19% after 13 months of GP supervision. In Practice B, the NP was autonomous in about three-quarters of consultations after 2 years on the job. These first cases provide some evidence that NPs could reach a relatively high degree of autonomy and might pose a potential solution for the decreasing numbers of GP home visits to multimorbid elderly in Swiss primary care.

Spiritual Dimensions of Nurse Practitioner Consultations in Family Practice.

Purpose of Study: To explore the spiritual dimensions of nurse practitioner consultations in primary care through the lens of availability and vulnerability. Design of Study and Methods Used: A hermeneutic phenomenological enquiry exploring the spiritual dimensions of primary care consultations consisting of two interviews per participant over an 18-month period was conducted with nurse practitioners in the United Kingdom. A purposive sample of eight nurse practitioners were recruited and interviewed. Interviews were fully transcribed and analyzed thematically. Findings: Participants identified that spirituality can be difficult to conceptualize and operationalize in practice. Participants articulated the meaning of spirituality and gave examples of when they had witnessed a spiritual dimension in practice. Key themes included how nurse practitioners conceptualize spirituality, the context for spirituality to be integrated into care, and the importance of spirituality as an aspect of holistic care. The concepts of Availability and Vulnerability were used intentionally as a lens in the study to explore whether these concepts and approaches to practice could enhance integration of spirituality into practice. Conclusion: Knowledge and understanding regarding spirituality in nurse practitioners consultations in primary care has been uncovered. A framework for operationalizing spirituality has been developed.

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

To advance understanding of the discrete nature of the communication processes and social interactions occurring in nurse practitioner consultations. 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. 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. 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: an observational interaction analysis of social interactions and consultation outcomes - ERRATUM.

To determine the discrete nature of social interactions occurring in nurse practitioner consultations and investigate the relationship between consultation social interaction styles (biomedical and patient-centred) and the outcomes of patient satisfaction, patient enablement, and consultation time lengths.

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

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. 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. 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. 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. 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. 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.

Nurse practitioner consultations in primary health care: an observational interaction analysis of social interactions and consultation outcomes.

To determine the discrete nature of social interactions occurring in nurse practitioner consultations and investigate the relationship between consultation social interaction styles (biomedical and patient-centred) and the outcomes of patient satisfaction, patient enablement, and consultation time lengths. A case study-based observational interaction analysis of verbal social interactions, arising from 30 primary health care nurse practitioner consultations, linked with questionnaire measures of patient satisfaction and enablement. A significant majority of observed social interactions used patient-centred communication styles (P=0.005), with neither nurse practitioners nor patients or carers being significantly more verbally dominant. Nurse practitioners guided the sequence of consultation interaction sequences, but patients actively participated through interactions such as asking questions. Usage of either patient-centred or biomedical interaction styles were not significantly associated with increased levels of patient satisfaction or patient enablement. The median consultation time length of 10.1 min (quartiles 8.2, 13.7) was not significantly extended by high levels of patient-centred interactions being used in the observed consultations. High usage levels of patient-centred interaction styles are not necessarily contingent upon having longer consultation times available, and clinicians can encourage patients to use participatory interactions, whilst still then retaining overall guidance of the phased sequences of consultations, and not concurrently extending consultation time lengths. This study adds to the body of nurse practitioner consultation communication research by providing a more detailed understanding of the nature of social interactions occurring in nurse practitioner consultations, linked to the outcomes of patient satisfaction and enablement.

A case study of nurse practitioner care compared with general practitioner care for children with respiratory tract infections.

To compare quality of care provided by nurse practitioners (NP) with care provided by general practitioners (GP) for children with respiratory tract infections (RTI) in the Netherlands. Nurse practitioners increasingly manage acute conditions in general practice, with opportunities for more protocolled care. Studies on quality of NPs' care for children with RTIs are limited to the US healthcare system and do not take into account baseline differences in illness severity. Retrospective observational cohort study. Data were extracted from electronic healthcare records of children 0-6years presenting with RTI between January-December 2013. Primary outcomes were antibiotic prescriptions and early return visits. Generalized estimating equations were used to correct for potential confounders. A total of 899 RTI consultations were assessed (168 seen by NP; 731 by GP). Baseline characteristics differed between these groups. Overall antibiotic prescription and early return visit rates were 21% and 24%, respectively. Adjusted odds ratio for antibiotic prescription after NP vs. GP delivered care was 1.40 (95% confidence interval 0.89-2.22) and for early return visits 1.53 (95% confidence interval 1.01-2.31). Important confounder for antibiotic prescription was illness severity. Presence of wheezing was a confounder for return visits. Complication and referral rates did not differ. Antibiotic prescription, complication and referral rates for paediatric RTI consultations did not differ significantly between NP and GP consultations, after correction for potential confounders. General practitioners, however, see more severely ill children and have a lower return visit rate. A randomised controlled study is needed to determine whether NP care quality is truly noninferior.

Consultation and Referral Patterns of Primary Care Nurse Practitioners

Background/Aims: The aims of the Primary Care Nurse Practitioner Consultation & Referral Patterns study included: a) determining the percentage of patients for which primary care nurse practitioners (NPs) request referrals or formal consultations; and b) exploring the patient, provider and system characteristics associated with variation in consultation/referral. Specifically, the project will contribute to understanding the decision-making models for when and how patients are referred by NPs to physicians and other health care providers.

Nurse-led supportive care management: a 6-month review of the role of a nurse practitioner in a chemotherapy unit

This case study evaluates the oncology nurse practitioner (NP) role in a chemotherapy unit. The NP works in the cancer centre of a major metropolitan public hospital. The NP role was established in the chemotherapy unit in 2007. The NP reviews all patients that have an unscheduled presentation to the unit, with symptoms relating either to their disease or treatment. All unscheduled occasions of service provided by the NP in the chemotherapy unit over 6 months were recorded. Data were collected on patient demographic characteristics, medical problems and reason for presentation. Data on duration of care, interventions and outcomes administered by the NP were captured. There were 87 occasions of service (72 patients) during the study period. Nausea, vomiting or dehydration were the most common presenting problems and most presenting problems were moderate or severe (n = 73, 84%). The median time to review for the NP was 5 min and nearly all consultations (n = 83, 96%) took 30 min or less. Following NP consultation, most occasions of service did not require subsequent hospital admission (n = 52, 60%), medical advice (n = 61, 70%) or medical review (n = 75, 86%). The NP is a valuable asset to a busy department, increasing access to timely and appropriate healthcare for patients on chemotherapy.

Patients’ assessments of consulting a nurse practitioner: the time factor

This paper reports a study exploring patients' views about consulting with a primary care nurse practitioner. United Kingdom based randomized controlled trials comparing the work of doctors and nurse practitioners add considerable weight to the view that patients tend to be more satisfied with primary care nurse practitioner consultations. However, there is a need for qualitative research to explore issues raised by the trials. A judgement sample of 10 patients consulting with a primary care nurse practitioner was drawn. In-depth interviews were conducted and analysed thematically. The data were collected in 2000-2001. The following themes were identified in the data: time spent in the consultation; and time as a commodity in patients' lives. Time matters to patients when they consult on their health, whether it is time to discuss problems or time saved as a result of having issues resolved, thus minimizing further visits. Factors associated with the style and emphasis of consultations are also important. Understanding the relationship between time, and style and emphasis of consultation may help to explain patients' satisfaction with primary care nurse practitioners.

A case study of styles of patient self-presentation in the nurse practitioner primary health care consultation

This case study explores the patient self-presentational aspects of social interactions occurring during nurse practitioner consultations in primary health care. Previous consultation communication research has revealed that styles of patient self-presentation have an effect on the process and outcomes of consultations. However, it is noted that available consultation communication research is focused on doctor-patient interactions. Accordingly, this research aimed to redress the medically focused imbalance in consultation communication research by investigating and identifying the possible effects of patient self-presentation styles on the process and outcomes of nurse practitioner consultations. An observational case study was undertaken in a nurse-led primary care walk-in clinic, utilizing multiple methods of data collection including: direct observations of nurse practitioner consultations, postconsultation semi-structured interviews with nurse practitioners, and a field journal. Two sample groups were used: a purposive sample of 15 patients attending the walk-in clinic with upper respiratory tract infections (URTI), and a convenience sample of six nurse practitioners employed at the same clinic. Five different styles of patient self-presentation were identified, which all had variant effects on the process and outcomes of the nurse practitioner consultation. These styles included: Seekers (patients seeking treatment); Clinical Presenters (patients presenting clinical histories); Confirmers (patients checking the severity of their illnesses); Seekers to Confirmers (patients who initially seek treatment, but who change to a confirmatory style); Anticipators (patients who anticipate their need for treatment). The nurse practitioner participants were found to be flexibly responding to these styles of patient self-presentation, as an attempt to maximize patient satisfaction with their consultations. It is suggested that the observed nurse practitioners were able to flexibly modify their consultation communication strategies in response to different patient self-presentation styles, which helped resolve the tensions existing between the patients’ own reasons for consultation attendance and their actual clinically assessed needs for treatment.

Nurse practitioner consultations: communicating with style and expertise

Susan Smith examines the structure, process and outcomes of the nurse practitioner/patient relationship and the skills required

Patients' perceptions of ߢuncertainty' in nurse practitioner consultations

The aim of this qualitative study was to explore patients' perceptions of consulting with a nurse practitioner in situations of clinical uncertainty. Uncertainty in this context is defined as one where there is no obvious diagnosis, treatment or where the outcome of the consultation is not definite. Three general practice sites were recruited to participate. 43 patients who consulted with one of three nurse practitioners were interviewed using a semistructured schedule. The nurse practitioners identified uncertainty in 30 of these consultations; only two patients expressed any awareness of uncertainty with the consultation. The results showed that patients appear to accept that there will be a level of uncertainty in some consultations. Recognition of uncertainty within the consultation does not appear to have a negative effect on patients' perception of the nurse practitioner as they feel that the nurse will refer to a doctor if necessary.

A primary health care team's views of the nurse practitioner role in primary care

The study reported here is one part of a wider study, evaluating the role of the nurse practitioner (NP) in primary care This part of the study focussed on the views of the primary health care team (PHCT) regarding their experience of working with two NPs. A project to place Master's prepared nurse practitioners (NP) in general practitioner practices was undertaken with the intention of more fully meeting the needs of practice populations in a deprived inner city area. The roles were supported and funded by the health authority and the placements were intended to be time limited with placement and funding to be reviewed. The project incorporated a planned evaluation of the role and this included a study of consultation patterns, caseload and this particular element, a study of PHCT members' attitudes to and experiences of the role. A purposive sample of 27 staff were interviewed using a partially structured interview format. Each interview lasted around 30 minutes with two researchers undertaking both collection and analysis of the interview data. Subsequently, an additional six staff were also interviewed in an opportunistic manner, at their request. The findings identified two main foci of the NP; as an ‘extra pair of hands’ and as a colleague undertaking a different, valuable and complementary service to existing staff. The pivotal role of the receptionist in the integration of the new role in to the practice and the acceptance of it by patients was clear. General practitioners (GPs) exhibited paradoxical views, particularly with respect to problems of throughput; the NP having longer appointments and therefore usually undertaking fewer consultations than GPs in any session, leading to perceptions of an expensive and perhaps less effective service in terms of its effect on the workload. Within the same interview however, GPs discarded throughput as an effective measure of patient care and highlighted the many benefits of NP consultation. This tension between cost and effectiveness would benefit from more effective analysis and evaluation. The members of the PHCT express many different views, often related to their professional priorities, but all appear to support the NP role enthusiastically, considering it a positive step which benefits the team, patient care and choice.

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

Objective: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting.Design: Systematic review of randomised controlled trials and prospective...

Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care

Objective: To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.Design: Multicentre randomised controlled trial of patients requesting an appointment the...

Testing a rating scale of video-taped consultations to assess performance of trainee nurse practitioners in general practice.

Nurse practitioners (NPs) in the United Kingdom are taking on some of the consultation work previously done by general practitioners (GPs) without there being any established professional standards that they must achieve before doing so. There is a need to develop and test methods of assessing their consultation performance for reasons of professional accreditation and patient safety. 1. To make independent summative assessments of trainee nurse practitioners' (TNPs) consultation performance. 2. To assess the validity and reliability of an existing video-taped assessment tool. Four TNPs taking part in the EROS (extended roles of staff) study video recorded seven or eight consecutive consultations with typical patients during one surgery. Each consultation was rated nine times by members of a panel comprising eight independent GP trainers, four NPs and the GPs and TNPs in the EROS practices. A rating scale developed by Cox & Mulholland was used for the purpose. Eight of the 37 items and four consultations had more than 10% missing data, mean = 7.7 items per rater. Factor analysis yielded a single factor solution explaining 32.6% of the variance and indicated that items could be summed to provide a single score. Internal consistency was high, alpha coefficient = 0.92. Individual differences between raters in scoring consultations were taken into account in providing a score for each consultation. Scores obtained were found to cluster at the positive end of the distribution indicating a high level of performance. Greater differences were found between scorers than between consultations. This instrument is appropriate for scoring NP consultations and this small sample was rated as showing a uniformly high standard of performance. Some items could be deleted since they do not feature in the range of consultations currently performed. If this or a similar tool was to be adopted more widely for summative rating purposes then it should be tested rigorously for validity and reliability, training should be given to raters and criteria provided by which to make judgements.