Nurse practitioners (NPs) are becoming more prominent in the Canadian healthcare system. In 2010, there were just under 2500 NPs in Canada, which represents a 25% increase since 2006 (Canadian Institute for Health Information, 2010). NPs have existed for more than 30 years with the role of the NP grounded in the discipline of nursing. The effectiveness of the NP as a primary care provider has been compared to that of physicians in numerous studies over the past three decades. These studies have repeatedly indicated that care provided by NPs in a primary care setting for common illnesses/presentations, and patient satisfaction, is equal to that of physicians, as well as cost-effective (Brown & Grimes, 1995; Horrocks, Anderson, & Salisbury, 2002; Mundinger et al., 2000; Spitzer et al., 1974).
Research further suggests that patients find their encounters with NPs comparable to physician care, but often are more satisfied with certain aspects of their care (Horrocks et al., 2002). For example, in comparison to their physician encounters, patients reported that NPs offered more health-related information, and consultations were significantly longer in duration (Horrocks et al., 2002; Kinnersley et al., 2000). In a literature review of NP–patient interactions, patient-centered communication styles were found to improve patient satisfaction, increase adherence to treatment plans, and positively impact patient outcomes (Charlton, Dearing, Berry, & Johnson, 2008). When interviewed about their practice, NPs accorded themselves certain approaches to interacting with patients—including openness, connection, concern, respect, reciprocity, competence, and time (Kleiman, 2004). From the patients' perspective, time spent to discuss health problems and time saved when issues are resolved during the consultation was deemed to matter in their satisfaction with NP care (Williams & Jones, 2006).
A study on the interaction of NPs in primary care identified three types of goals: (a) instrumental goals (issues pertaining to health care, diagnosis, treatment, information exchange, and resource management), (b) relational goals (relationship-building, compliance-gaining, anxiety management, and identity management), and (c) self-presentational goals (establishing expertise, demonstrating professionalism and compassion) (Babler-Schrader & Schrader, 2011). The purpose of this study was to further understand the dynamics of NP–patient interactions as the NP–patient relationship develops over time. The process of the clinical encounter is described within the context of an established nursing theory: King's theory of goal attainment.
Conceptual framework for the study
According to King's theory, nursing is defined as a process of human interactions whereby the nurse and patient each perceive the other, set goals, and agree on a means to achieve the goals. A major concept in this theory is transaction that describes the transfer of values, aspirations, and wants between nurses and patients. These are goal-directed human behaviors that are observable, whereby the nurse and patient share frames of references, establish a reciprocal relationship, and negotiate mutually set goals. Transactions are defined as “purposeful interactions where human beings communicate with their environment to achieve goals that are valued” (King, 1981, p. 82). When transactions are made, tension or stress is reduced in a situation, which can lead to growth and development (King, 1981).
Based on her pioneer field study of nurse–patient interactions, King (1981) describes a disturbance as one of the key elements in nurse–patient interactions that leads to transactions. A disturbance is defined as the identification of a problem or concern in the patient environment where there is incongruence of perceptions between the nurse and patient. During a disturbance, an exchange of values and expectations occurs. There is a sharing of ideas until there is mutuality and ultimately agreement toward goal setting. This agreement, which was triggered by a disturbance, leads to transactions.
Goals are attained when transactions occur between nurses and patients. King's theory implies that there should be a positive correlational relationship between the presence of transactions and patients' perspectives of trust and satisfaction as outcomes of the NP–patient relationship. Of the numerous practice and research applications of King's theory, this study is the first to apply the theory to examine NP–patient interactions.
To capture the evolution of relationship building and goal setting, this study was designed as a longitudinal observation of NPs and their patients over three consecutive visits in 1 year.
After approval from the Health Research Ethics Board at the University of Manitoba, NP study participants were recruited from four primary care clinics. Criteria for recruitment included Master's prepared female NPs with at least 1 year of practice experience in community-based clinics. Clinic support staff identified potential study patients who were English speaking, were at least 18 years of age, and had not previously received care from the NP. The research coordinator contacted the potential participant by telephone to describe the study and recruit the participant. The final convenience sample included four NPs and six patients.
At the patient's first appointment with the NP, the research coordinator met with the patient to review the study process and obtain written informed consent. Three consecutive clinical encounters between the NP and the patient were video-taped. After the first and third visits, the patient completed the Trust in Physician Scale (Thom, Ribisl, Stewart, & Luke, 1999) and the Visit-Specific Satisfaction Questionnaire (Davies & Ware, 1991; Rubin et al., 1993).
This study applied a triangulated approach to the data that included qualitative discourse analysis, a quantitative analysis of the content of the encounters using the Davis Observation Code (Callahan & Bertakis, 1991), and content analysis based on King's theory. The focus of this article is the audiotape component of the videotape data.
Seven hours of audiotape data of NP–patient dyads over three sequential clinic encounters were transcribed and entered into NVivo 8.0, software program. A coding legend was developed by two NPs on the research team using King's definitions of the elements of transactions. Face validity was established through a review process with other members of the research team. To test for reliability, transcripts were coded independently by two of the researchers and by the research assistant. Reliability of the coding system was tested independently by the researchers on three more occasions during the data analysis process. A high degree of agreement (92%) was found consistently during this process.
Within the six NP-PT dyads, there were a total of 98 topics discussed with an average of 16 topics per dyad over three clinical encounters. Transactions occurred in 57% of these topics. The NP initiated the majority of topics where transactions occurred (66%).
Disturbances were found in all the clinical encounters. A total of 71 disturbances occurred. Once a disturbance occurred, intense information exchange followed. Information exchange revolved around goal achievement: exploring a means to achieve a goal, agreeing on a means to achieve a goal, and mutual goal setting. Health promotion and symptom management topics were found to have the most intense information exchange. Transactions followed the majority of disturbances (79%). All transactions were preceded by a disturbance.
Of the topics that did not lead to transactions, 65% were not preceded by disturbances. When no disturbances occurred, the discussions were around social exchange, symptom reporting, health history taking, physical examination, explanation of the NP role, and explanation of clinic processes.
Social exchange often opened and closed the clinical encounters and was skillfully used to create context for behavior change. Attending to the social relationship was a prominent feature in the majority of interactions. The interpersonal skills of the NP were crucial in building a strong relationship with the patient. Used inappropriately or at the wrong time, a social interaction undermined relationship-building. However, when applied in the right context, social cues worked to strengthen the therapeutic bond with the patient.
One method of constructing a social relationship was “the reveal of self” by either the nurse practitioner or the patient. Revealing personal information concerning oneself demonstrated trust and amicability with the other person. All patients in this study reported high scores in trust with the NP and all were highly satisfied with the care they received.
The following is an example of a dialogue revolving around the patient's cholesterol results and the decision-making process on whether to start medications. This interaction includes the elements of information exchange, disturbance, exploring, and agreeing to the means to achieve a goal that ultimately leads to a transaction.
Side bar: The disturbance begins when the NP identifies a clinical concern.
- NP:Okay so I've got all your blood work back. Everything looks very good. Your cholesterol is what we would say, borderline.
- PT:That's what I, yeah, I heard it before. At one time it was good but I think they told me they changed the way they looked at it ….
Side bar: An exchange of information and expectations follows.
- NP:Yeah they did. They made it a bit tighter. We look at your age and the fact that you're a woman and there's so many points that you get for certain levels. And so when I plot out your points, I come up with this number that tells us that you have a moderate risk of having coronary artery disease within the next 10 years … that means, you know, angina, or more at risk for a stroke.
- They give you some guidelines, with a person of your age and your numbers, we would treat you with medication if this number (LDL) was greater than or equal to 3.5 or your total cholesterol HDL ratio is greater than or equal to 5.
- Now for you … this LDL is actually 5.35, so you are greater than that. Okay? But this ratio is very good.
- Pt:Is that the good one?
- NP:The HDL is the good one
- NP:We like to see it higher and yours is good. Your HDL is supposed to be higher than 0.9 and yours is 1.96, so you know, that's good. It's just we need this LDL, the bad cholesterol to come down. I mean we should treat you with medication to bring that down. Because diet alone might not, well probably, will not do much if anything to that number. You don't smoke so that's really good and I don't think we had any really family history of high…
- Pt:My mother has high cholesterol, super high though.
- Pt:Yeah, she's been taking pills for a long time. Like I think I remember I told my other doctor that she had super high, and she says that probably isn't why you have yours because hers is like, really high.
Side bar: The NP and patient then explore different means to achieve the goal.
- NP:There's only so much we can do with diet and exercise and not smoking, but then we need a little help with medication. So, um, how do you feel? Would you like to see the dietician to go over a little bit of the low cholesterol? Or do you think your diet's pretty good.
- Pt:I think my diet's pretty good actually. And I am exercising
- Pt:Okay. Is there any like natural like, um, natural thing you can take that would help this too?
- Pt:I think more like flax seed oil or something like that beyond what I might be eating?
- NP:Well niacin might help you. Um, you need quite a big dose of it.
- NP:And the only thing with niacin is you get this flushing. There are types of niacin that I would order by prescription that would say the anti-flush one…but it's extremely expensive.
Side bar: When negotiating and exploring the means to achieving the goal, the NP acknowledges the patient's values and gives options.
- NP:Okay. Now if, if you want to try, we could, let me recheck this in 6 months' time if you think that you would like to try over-the-counter niacin. Seeing if you can make any other…this exercise something new now?
- Pt:Ah Curves, I've been going since April.
- Pt:It would be new for this April of last year.
- NP:Uh, huh. I mean you can certainly … I'm not here to push pills on you.
- NP:I'm just saying you know, because you've done, you're doing a pretty good job with your lifestyle, so you're probably going to end up on medication.
Side bar: A disturbance occurs again as the patient expresses concern.
- NP:If you want to give it a try (NP is referring to other options), I'm willing to …
Side bar: The NP acknowledges the patient concern.
- Pt:No, I'll go on medication now.
Side bar: The patient agrees on means to a goal and a transaction begins.
- NP:I will give you some samples. We'll start you on something low and see, for a couple of weeks, and see how you tolerate it?
- Pt:Okay. I think that sounds good.
- NP:Okay, do you have a concern or a fear of that? [NP is referring to fear of side effects.]
Side bar: A transaction is completed.
This excerpt is representative of a typical disturbance leading to a transaction found in the NP–patient encounters.
This study demonstrated an application of King's theory to the study of NP–patient clinical encounters. Disturbances and transactions emerged as valid elements in NP–patient interactions. Disturbances, whether they were NP- or patient-identified concerns, provided momentum to the interaction. Two-way information exchange became more intense when disturbances occurred during the encounter. The observation in this study where 79% of disturbances resulted in transactions illustrates the importance for NPs to recognize and capitalize on these opportunities.
The longitudinal design of this study demonstrated how the process of some transactions can occur over several clinical encounters. In this study, those disturbances that did not result in transactions (21%) occurred primarily during the third visit. It is plausible that these disturbances are in a “holding pattern” and, if managed appropriately, these could transpire into transactions in future clinical encounters.
The following relationship building elements found in the data analysis have not been previously noted in other applications of King's theory: social exchange, symptom reporting, health history sharing, physical examination, role explanation, and information around clinical processes. Our findings of the skillful use of social exchange by the NP is consistent with Haggerty and Patusky's (2003) framework of human relatedness where the importance of “small talk” is identified as a means to discover commonalities and mutuality. Acquiring information on a social level in addition to health information influenced perceptions of the NP and the patient, ultimately impacting the interaction. Further research is needed to test the hardiness of these elements. Figure 1 is a schematic of King's theory of goal attainment with proposed additions of these elements to describe the NP–patient interaction.
This arm of the larger study is limited by the analysis of only the audio component of the video-taped interactions. Verbal and visual data analysis of two cases is published elsewhere: https://www.uleth.ca/dspace/handle/10133/3247.
Although our findings are consistent with King's theory describing a positive relationship between transactions and patient's trust and satisfaction, the instruments used (Trust in Physician Scale and Visit-Specific Satisfaction Questionnaire) were not found to be sensitive enough to capture variations in this small sample.
Implications for nursing practice
The findings of this study add to the limited literature on NP–patient communication. Primary care NPs develop routines and templates to increase efficiency in their clinical encounters. One study of NP–patient interaction found that the majority of NPs do not use a patient-centered communication style (Berry, 2009), possible due to time constraints. This study suggests King's theory of goal attainment as a framework to describe and guide NP–patient interactions. The findings encourage NPs to be more reflective of their practice. By recognizing disturbances in clinical encounters and embracing these as opportunities for mutual goal setting, NPs become more patient-centered. As preceptors, NPs can articulate to their students the importance of attending to disturbances in a clinical encounter and promoting goal achievement through patient-centered communication.
King's theory exemplifies respect for patients and places importance on information exchange, goal setting, and patient-centered care. This application of King's theory of goal attainment to NP clinical encounters reinforces the nursing foundations underlying advanced practice nursing.
This research was supported by a grant from the Social Sciences and Humanities Research Council of Canada. The authors wish to acknowledge their research assistant, Ryan Iwasiw MN, RN, NP, who provided valuable insight in the coding of data and in the analysis of the interactions between nurse practitioners and their patients.
Babler-Schrader, E. L., & Schrader, D. C. (2011). Interaction goals in the primary care medical interview. Journal of American Academy of Nurse Practitioners
Berry, J. (2009). Nurse practitioner-patient communication styles in clinical practice. Journal for Nurse Practitioners
Brown, S., & Grimes, D. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary care. Nursing Research
Callahan, E., & Bertakis, K. (1991). Development and validation of the Davis Observation Code. Family Medicine
Canadian Institute for Health Information. (2010). Nursing supply outpacing Canadian population growth: 25% increase in nurse practitioners in one year
. Retrieved from www.cihi.ca/CIHI-ext-portal/internet/EN/QUICK_STATS
Charlton, C. R., Dearing, K. S., Berry, J. A., & Johnson, M. J. (2008). Nurse practitioners' communication styles and their impact on patient outcomes: An integrated literature review. Journal of American Academy of Nurse Practitioners
Davies, A., & Ware, J. (1991). GHAA's consumer satisfaction survey and user's manual
. Washington, DC: Group Health Association of America.
Haggerty, B., & Patusky, K. (2003). Reconceptualizing the nurse-patient relationship. Journal of Nursing Scholarship
Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal
King, I. (1981). A theory for nursing: Systems, concepts, process
. New York: John Wiley & Sons, Inc.
Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard, L., Turton, P., … Rogers, C. (2000). Randomized controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. British Medical Journal
Kleiman, S. (2004). What is the nature of nurse practitioners' lived experiences interacting with patients? Journal of American Academy of Nurse Practitioners
Mundinger, M., Kane, R., Lenz, E., Totten, A., Tsai, W., Cleary, P., … Shelanski, M. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians. A randomized trial. Journal of the American Medical Association
Rubin, H., Gandek, B., Rogers, W., Kosinski, M., McHorney, C., & Ware, J. (1993). Patient's ratings of outpatient visits in different practice settings. Results from the medical outcomes study. Journal of the American Medical Association
Spitzer, W. O., Sackett, D., Sibley, J., Roberts, R., Gent, M., Kergin, D., Hackett, B., Olynich, A. (1974). The Burlington randomized trial of the nurse practitioner. New England Journal of Medicine
Thom, D., Ribisl, K., Stewart, A., & Luke, D. (1999). Further validation and reliability testing of the Trust in Physician Scale. The Stanford Trust Study Physicians. Medical Care
Williams, A., & Jones, M. (2006). Patients' assessments of consulting a nurse practitioner: The time factor. Journal of Advanced Nursing