A study comparing the A study comparing the consultation practice of consultation practice of

Advanced Nurse Practitioners Advanced Nurse Practitioners and General Practitioners in and General Practitioners in

Primary CarePrimary Care

Dr Hilary PaniaguaDr Hilary Paniagua

AimsAims

• To find out what ANPs doTo find out what ANPs do

• What is advanced practiceWhat is advanced practice

• ANPs and GPs worked together doing the ANPs and GPs worked together doing the same rolessame roles

• Training practice within an urban general Training practice within an urban general practice in the West Midlandspractice in the West Midlands

• Emergency surgeries of 2 ANPs with MSc in Emergency surgeries of 2 ANPs with MSc in Advanced Practice and 2 GPs Advanced Practice and 2 GPs

Design of the studyDesign of the study

Chosen methodology Chosen methodology

• Capture natural occurring talk by video Capture natural occurring talk by video recording GP and ANP emergency recording GP and ANP emergency consultations consultations

• Structuralist and poststructuralist linguistic Structuralist and poststructuralist linguistic philosophy that are access to reality is philosophy that are access to reality is through language.through language.

• Words are considered to be how individuals Words are considered to be how individuals experience themselves and others within the experience themselves and others within the world, and how these experiences are world, and how these experiences are interpretedinterpreted

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.

Transcript D2. 3 Consultation with GP and elderly patient with anginaTranscript D2. 3 Consultation with GP and elderly patient with angina001 P3: look I (2.0) can’t get me breath when I start walking001 P3: look I (2.0) can’t get me breath when I start walking002 DA: right 002 DA: right (patient prods at his chest) (patient prods at his chest)003 P3: and the (2.0) I have to be walking (1.0) pains003 P3: and the (2.0) I have to be walking (1.0) pains004 DA: 004 DA: you’re getting painsyou’re getting pains005 P3: yeah005 P3: yeah006 DA: when you’re walking are [you006 DA: when you’re walking are [you007 P3:007 P3: [it’s not a pain its tightness = [it’s not a pain its tightness =008 DA: = right =008 DA: = right =009 P3: right009 P3: right010 DA: how long has that been going on [ for now?010 DA: how long has that been going on [ for now?011 P3:011 P3: [it’s gradually come on for about the last three [it’s gradually come on for about the last three 012 P3 weeks it’s just getting worse and worse like012 P3 weeks it’s just getting worse and worse like013 DA: ok013 DA: ok014 P3: yeah014 P3: yeah015 DA: are you breathless every time you’re walking015 DA: are you breathless every time you’re walking016 P3: yeah I am016 P3: yeah I am017 DA: or is it just in [certain conditions017 DA: or is it just in [certain conditions018 P3018 P3 [no I am now [like when I first started it was just (2) I walked yer [no I am now [like when I first started it was just (2) I walked yer 019 DA:019 DA: [ok [ok020 P3: know cos I walk quite a bit like (1) I’ve had a bypass020 P3: know cos I walk quite a bit like (1) I’ve had a bypass021 DA: [right021 DA: [right022 P3: [as I walk[022 P3: [as I walk[023 DA 023 DA [now (2) have you had angina pain before (1) given [now (2) have you had angina pain before (1) given

Transcript A2. 1-2 Consultation with ANP and patient who wants to talkTranscript A2. 1-2 Consultation with ANP and patient who wants to talk001 P2 I can’t really say you’re going to help me but I wanted to talk to you about it =001 P2 I can’t really say you’re going to help me but I wanted to talk to you about it =002 Su: = that’s fine=002 Su: = that’s fine=003 P2: = I haven’t sort of felt right for weeks you know [ just sort feel its not going003 P2: = I haven’t sort of felt right for weeks you know [ just sort feel its not going004 Su: [mumm004 Su: [mumm005 P2: away this ache and this feeling that I’ve got I’m not just right and I felt my arms kind of 005 P2: away this ache and this feeling that I’ve got I’m not just right and I felt my arms kind of 006 P2: itching now today I haven’t felt it but everyday I’m scratching at 006 P2: itching now today I haven’t felt it but everyday I’m scratching at my arms the back of my my arms the back of my 007 P2: neck remember when I had that bad fall on the a bus remember at X =007 P2: neck remember when I had that bad fall on the a bus remember at X =008 Su: = yes yes =008 Su: = yes yes =009 P2: = now they said I had a crack ah crack in my head and I had a break in my collar bone yes 009 P2: = now they said I had a crack ah crack in my head and I had a break in my collar bone yes 010 P2: 010 P2: that’s right =that’s right =011 Su: = yes that’s right =011 Su: = yes that’s right =012 P2: = now honestly sometimes when I turn my head and I’ve got my hair looks like up the back so 012 P2: = now honestly sometimes when I turn my head and I’ve got my hair looks like up the back so 013 P2: often will it wear off that’s what I wanted to say013 P2: often will it wear off that’s what I wanted to say014 Su: how long ago now was that?014 Su: how long ago now was that?015 P2: it’s about seven months [eight months ago[ June it was015 P2: it’s about seven months [eight months ago[ June it was016 Su:016 Su: [yeah [mumm [yeah [mumm017 Su: I wonder if you’ve got perhaps a little bit of arthritis in the back of your neck as well 017 Su: I wonder if you’ve got perhaps a little bit of arthritis in the back of your neck as well 018 Su: perhaps it’s exaggerated it a little bit =018 Su: perhaps it’s exaggerated it a little bit =019 P2: = oh do you think so?019 P2: = oh do you think so?020 Su: don’t know we’ll have a look at you 020 Su: don’t know we’ll have a look at you 021 P2: so well that’s a (.)[021 P2: so well that’s a (.)[022 Su: [now when did the irritation start =022 Su: [now when did the irritation start =023 P2: = it’s just itching I feel like scratching my neck to sometime and and this arm mind you did I 023 P2: = it’s just itching I feel like scratching my neck to sometime and and this arm mind you did I 024 P2: tell you about three weeks ago I had a a car knocked me down024 P2: tell you about three weeks ago I had a a car knocked me down025 Su: ohh dear =025 Su: ohh dear =026 P2: = everything happens at once but all my 026 P2: = everything happens at once but all my lifelife I’ve never had anything up until two years ago I’ve never had anything up until two years ago 027 P2: and I’ve three things [one after the other in two years027 P2: and I’ve three things [one after the other in two years028 Su: [mumm028 Su: [mumm029 Su: and how did your road traffic accident happen029 Su: and how did your road traffic accident happen030 P2: well I was crossing the road, not at the crossing needless to say, but you know going along X030 P2: well I was crossing the road, not at the crossing needless to say, but you know going along X031 P2: road to X, [ lights were stopped at X road, [so I knew there was nothing coming at the next 031 P2: road to X, [ lights were stopped at X road, [so I knew there was nothing coming at the next 032 Su: [mumm [mumm032 Su: [mumm [mumm033 P2: stop after that the crossing, the stop, so the next car I could see was way past the school 033 P2: stop after that the crossing, the stop, so the next car I could see was way past the school 034 P2: 034 P2: there, youthere, you know, and it was belting along. I tho I’ll make know, and it was belting along. I tho I’ll make that easy cos I’m quite a quick that easy cos I’m quite a quick 035 P2: 035 P2: walker you know,walker you know, and I was about that much off the pavement, and I was about that much off the pavement, now this is, that’s the truth, now this is, that’s the truth, 036 P2: about that much off the pavement, he says he didn’t see me can you imagine? I was crossing 036 P2: about that much off the pavement, he says he didn’t see me can you imagine? I was crossing 037 P2: the road, no no traffic coming that way and he said he didn’t see me, and I said well you 037 P2: the road, no no traffic coming that way and he said he didn’t see me, and I said well you 038 P2: shouldn’t be driving if you didn’t see me, well anyhow to cut a long story short, he he 038 P2: shouldn’t be driving if you didn’t see me, well anyhow to cut a long story short, he he 039 P2: swerved he put his brakes on he swerved to the centre, well of course the next car coming039 P2: swerved he put his brakes on he swerved to the centre, well of course the next car coming (leans fast forward) (leans fast forward) 040 P2: 040 P2: along so fast he came at along so fast he came at me,me, the next car the next car came at me you know and knocked me and I sort of came at me you know and knocked me and I sort of 041 P2: myself lying just like exactly like I’ve shown you 041 P2: myself lying just like exactly like I’ve shown you (11 lines missing about GP)(11 lines missing about GP)053 P2: after that I just wanted to talk to you about it what do you think053 P2: after that I just wanted to talk to you about it what do you think054 Su: um I’m sure he’s right may I have a little look at you shall I?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)(consultation proceeds to a full examination)

ANPs had a different relationship ANPs had a different relationship with patients with patients

• Patients interacted more with ANPs because:Patients interacted more with ANPs because:a) ANPs worked to diminish social distance with a) ANPs worked to diminish social distance with

patientspatientsb) Patients were always aware of what nurses b) Patients were always aware of what nurses

were thinking and why they did things as were thinking and why they did things as they used online thinking (voice of nursing)they used online thinking (voice of nursing)

c) ANPs worked within a medical framework c) ANPs worked within a medical framework yet interweaved their nursing skills within yet interweaved their nursing skills within this (medico-nursing world)this (medico-nursing world)

The medico-nursing world/the ‘voice of The medico-nursing world/the ‘voice of nursing’nursing’

150 Sz:150 Sz: I’ll just get you some a leaflet (2.0) there are differentI’ll just get you some a leaflet (2.0) there are different151151 types of worms but the most common is the little tiny thread types of worms but the most common is the little tiny thread

worm[ whichworm[ which152 M:152 M: [right [right ANP turns to face motherANP turns to face mother153 Sz:153 Sz: is what you they um (1) I’ve got twins and um when the one of them is what you they um (1) I’ve got twins and um when the one of them

was was 154 154 six months old she actually passed a round worm which is like a white 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 155 earth worm and the only way she’d have picked that up was from dogs or 156156 and we didn’t have any so I don’t know whether the previous and we didn’t have any so I don’t know whether the previous

owners of theowners of the157157 house had a dog and she’d been crawling in the garden and I house had a dog and she’d been crawling in the garden and I

mean I nearlymean I nearly158158 died because this thing was [like six inches long and even though died because this thing was [like six inches long and even though

I’m medical I’m medical 159 M:159 M: [ohh no [ohh no160 Sz160 Sz I’d never seen something so I couldn’t quite work out whatI’d never seen something so I couldn’t quite work out what161 M161 M oh no and the fact it was coming from your own child you seeoh no and the fact it was coming from your own child you see162 Sz: um 162 Sz: um

ANPs used the strategy of thinking ANPs used the strategy of thinking aloud and ‘on-line’aloud and ‘on-line’

119 Su: ok um what could we put (.) it’s such a difficult spot isn’t it right on your eyelid 119 Su: ok um what could we put (.) it’s such a difficult spot isn’t it right on your eyelid ==

120 P2: = yes120 P2: = yes121 Su: normally I say use a bit of hydrocortisone which you can if you are extremely 121 Su: normally I say use a bit of hydrocortisone which you can if you are extremely

extremely extremely 122 careful =122 careful =123 P2: = yeah123 P2: = yeah124 Su: um if Claritin normally works that’s fine we could change your antihistamines =124 Su: um if Claritin normally works that’s fine we could change your antihistamines =125 P2: = um =125 P2: = um =126 Su: = and try something different126 Su: = and try something different 127 P2: well I had some Zertec on holiday cos I had a reaction to my suntan lotion =127 P2: well I had some Zertec on holiday cos I had a reaction to my suntan lotion =128 Su: = it’s an odd set up right128 Su: = it’s an odd set up right129 P2: but it I don’t know whether it was but I taking I took the first one at about 11 129 P2: but it I don’t know whether it was but I taking I took the first one at about 11

o’clock when o’clock when 130 P2: I started [to itch with this rash and then by about 4 o’clock I was zonked and 130 P2: I started [to itch with this rash and then by about 4 o’clock I was zonked and

they made methey made me131 feel131 feel132 Su: [yes132 Su: [yes133 P2: a bit sick 133 P2: a bit sick 134 Su: right so so stick to the Claritin then134 Su: right so so stick to the Claritin then

No verbal diagnosisNo verbal diagnosis

091 Sz: I can’t um find anything dramatic on your chest091 Sz: I can’t um find anything dramatic on your chest092 P2: no oh that’s something092 P2: no oh that’s something093 Sz: um and it’s one of those situations where isn’t it? where I am sure if you leave it long 093 Sz: um and it’s one of those situations where isn’t it? where I am sure if you leave it long

enough it enough it 094 Sz: would go away of its own accord =094 Sz: would go away of its own accord =095 P2: = yeah =095 P2: = yeah =096 Sz: but the fact that you’re feeling a bit tight096 Sz: but the fact that you’re feeling a bit tight097 P2: yeah097 P2: yeah (tilts head backwards and strokes throat) (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 098 Sz: it may very well be that at night that because your nose is blocked when you lie down it

drips to drips to 099 Sz: the back of your throat[099 Sz: the back of your throat[100 P2:100 P2: [mum[ [mum[

(makes a sweeping motion with both arms upwards backwards and forwards)(makes a sweeping motion with both arms upwards backwards and forwards)101 Sz:101 Sz: [rather than actually it being a chest infection but I can [rather than actually it being a chest infection but I can

seesee102 Sz: from the type of person that you’re not a great attender102 Sz: from the type of person that you’re not a great attender103 P2: no103 P2: no(14 lines ANP checking the infrequent history of visits)(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 that117 Sz: yeah no so I am quite happy to give you a week’s supply of an antibiotic because of that118 P2: thank you very much118 P2: thank you very much

Ideas on Advanced PracticeIdeas on Advanced Practice

• Involves the response created with Involves the response created with patientspatients

• Creating partnershipsCreating partnerships

• Seen in the voice of nursingSeen in the voice of nursing

• Is the creation of a medic-nursing Is the creation of a medic-nursing worldworld

• Involves strategies such as online Involves strategies such as online thinkingthinking

THANK YOU!THANK YOU!