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Qualitative Research

What is curbside consultation for the nurse practitioner?

Papermaster, Amy NP-C, PhD (Student)1; Champion, Jane Dimmitt PhD, DNP, FNP, AH-PMH-CNS, FAANP, FAAN (Professor)1

Author Information
Journal of the American Association of Nurse Practitioners: January 2021 - Volume 33 - Issue 1 - p 29-37
doi: 10.1097/JXX.0000000000000322
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Abstract

Introduction

Curbside consultation (CC) is the process used by providers to informally seek advice from one another regarding patient care without requesting formal consultation (FC) (Papermaster & Champion, 2017). Cook, Sorensen, and Wilkinson (2014) found that CC allows for a personalized bidirectional response that expedites patient care. A review of the literature identified a paucity of information concerning this process among nurse practitioners (NPs) (Papermaster & Champion, 2017). Preliminary assessment indicates that the most valued sources of knowledge among nurses and NPs are informal exchanges, social interactions, and personal experience (Voldbjerg, Grønkjær, Sorensen, & Hall, 2016) with social interactions providing a knowledge base more often than academic journals (Alving, Christensen, & Thrysøe, 2018). Nevertheless, further understanding of the process for CC among NPs is indicated (Liddy, Drosinis, & Keely, 2016; Pecina, Wyatt, Comfere, Bernard, & North, 2017) to inform NP education, practice, and research.

An understanding of the processes for CC and its impact on decision-making and ultimately patient outcomes is needed. The purpose of this study is to describe perceptions of the CC process for NPs.

Design and methods

A qualitative descriptive methodology was used to conduct in-depth and semistructured interviews. This less interpretive and theoretically based approach tends to draw from naturalistic inquiry for description of the phenomenon. Qualitative methodology is considered less interpretive and provides a means for consensus among investigators to explore experience and meaning. This research methodology drives for understanding through analysis and interpretation of meaning people attribute to phenomena (Sandelowski, 2000; Tong, Sainsbury, & Craig, 2007).

The investigators obtained institutional review board approval before recruiting study participants via convenience sampling. Eligibility criteria included the following: age 18 years or older, board-certified, English-speaking NPs currently practicing in either primary care or specialty care settings in a metropolitan area of the southwestern United States. Participants were approached either face-to-face or via email. Email invitation contained information about the study, eligibility criteria for participation, and researcher contact information. None of the eligible participants refused study participation or dropped out of the study. Each participant selected the site for conduct of the study interview: All participants selected the workplace for interviews with the exception of two participants who requested a home site. Only the participant and researcher were present during the interview.

The study interview began with an overview of the purpose and structure of the interview, processing of information received, and informed written consent. Participants verbalized an understanding that they may discontinue the interview at any time. The interview conducted once with each participant lasted approximately 40 minutes. The interview session was audiotaped, transcribed, deidentified, and then destroyed.

The researcher conducting the interview maintained neutrality and respectful rapport throughout the interview process and acknowledged personal interests in the study topic (Parahoo, 2014). The open-ended interview focused on the beliefs and values of NPs involved in CC and the process whereby CCs inform clinical practice. The interview guide allowed freedom to address the developing content while providing flexibility to frame questions in face-to-face interviews (Tong, Sainsbury, & Craig, 2007). Questions were designed to generate description of diverse CC experiences.

Data analysis

The interviews were transcribed verbatim through GMR Transcription Services© and reviewed in their entirety. The transcribed data and audio recordings were compared and amended for accuracy. All identifying information was removed. Inductive content analyses described NP perceptions of CC processes and their impact on patient care. Inductive content analysis, an investigative process to identify meaning, was selected given the dearth of studies in this matter (Elo & Kyngas, 2008). Coding of data based on interview questions identified structured themes. We also identified emergent themes not specifically driven by interview questions. For example, data captured for the question—“Are there rules for the person you are CC or seeking advice from?”—were coded by listing rules. This allowed comparison of responses when discussing this explicit concept.

The investigators used the ATLAS.ti data analysis software to organize data. Transcriptions were reviewed in their entirety multiple times to attain immersion. Reading word-by-word, codes created by highlighting exact words captured key thoughts or concepts (Hsieh & Shannon, 2005). We sorted categories and examined these for more specific similar and dissimilar contents for subcategories. Grouping of similar categories and similar subcategories was completed in the abstraction process. Each interview was reread and returned to the data to check the reliability of categories and subcategories thoughtful of the driving research question and conceptualization of CC in the literature.

After initial data analyses, we reviewed data from primary and specialty NPs (SNPs). If there was consensus among these 2 groups, this delineation was not included in the findings. Distinct differences in findings of specialty and primary care NP (PCNP) interviews were reported.

After data analyses, member checks with several participants for accuracy and resonance with experiences occurred to verify findings. Ample quotations were included to substantiate findings. This process was repeated later to establish credibility and confirmability (Graneheim & Lundman, 2004).

Sociodemographics

Thematic saturation required a total of 20 interviews. Most participants were women (75%) and between 30 and 50 years of age (70%) and non-Hispanic White (85%). Half of all participants identified as primary care providers in family practice, internal medicine, or pediatric settings, whereas 50% identified as specialty NPs in diverse settings. Urban (80%) or suburban (15%) practice settings were identified by the majority, whereas no one practiced in a rural setting. Most NPs practiced in outpatient (85%), nonacademic (60%) settings. Descriptions of relationship with supervising physician ranged from meeting infrequently (5%) or only as mandated by state laws (10%) to practicing alongside the supervising physician and sometimes seeing patients together (40%) or frequently seeing patients together (45%). The highest education reported by a majority (55%) was Master of Science in Nursing. One participant practiced alone, whereas two participants had 10+ clinicians in their current practice. Most participants (80%) practiced since 2001 as NPs with certification from the American Academy of Nurse Practitioners (30%) or American Nurses Credentialing Center (50%). Average years in NP practice was 9.325 (SD 8.61) and 50% graduated between 2011 and 2015 (Table 1).

Table 1
Table 1:
Characteristics of participants

Findings

Multiple themes depicted NP perceptions of CC. For the sake of consistency in describing the CC process, the person seeking advice is the “seeker” and the person sought for advice is the “expert.” The first theme describes perceptions about when to use CC instead of FC or other resources.

What is curbside consultation?… “Find somebody who has synthesized all that mass information in a practical way”

Participants described CC as a process used when they perceive the patient's condition is manageable without FC. Curbside consultation offers bidirectional or conversational direct answers to specific questions. It allows a real-life, practical, hands-on, front-line application of information and narrowing of guideline choices. “Real-life” is abundant in descriptions of advantages of CC. Timely, quick, or convenient answers are preferable via CC. Participants viewed being able to draw on their own and others' experiences as invaluable when the patient does not fit into the … description for management of care. Curbside consultation provides a second opinion on how to apply these guidelines to a patient. Application of the … guidelines requires clinical discretion as described in the following excerpt.

Not everything can be fixed … so you're talking about patients … there is no textbook where 100% of things in that textbook can be applied to 100% of the patients. So, you absolutely have to have clinical judgment, you absolutely have to be able to use your clinical judgment and not just take what … says … I think those are skills you build up with your nursing background … with your advance practice … you know experience (Inpatient Intensive Care Unit [ICU] Acute Care Nurse Practitioner [ACNP] 5 years)

Participants described CC as a resource in which clinicians benefit from other experiences, filling knowledge gaps and receiving confirmation in their patient management. “I always benefit from getting advice on something you don't know a lot about … or having a different way at looking at things is better for patients” (Outpatient Women's Health Family Nurse Practitioner [FNP] 19 years). Many expressed that CC is unique for learning what the expert would do in the same circumstance. Validation was prominently a reason for seeking information in patient management. The NP is able to fact-check a question or get clarification on an unfamiliar topic when it just does not sound right. Participants reportedly appreciated the assurance that providers are doing the right thing for patients. “Find somebody who has synthesized all that mass information in a practical way” (Outpatient Family Practice FNP 0.5 years). “(CC) … extends all of our education” (Outpatient Internal Medicine FNP 1 year).

Other terms for curbside consultation… “Hallway medicine,” “Informally consulting,” “Hallway consultation”

When discussing CC, other terms were used synonymously: “hallway medicine,” “informally consulting,” “hallway consultation.” Curbside consultation, referred to as “outsourcing knowledge” or a quick information transfer that is individual and conversational, was favorable. The curbside consultation exchange allows colleagues to have back and forth conversation, consider both sides of a particular issue, or bounce ideas back and forth. Some practices more commonly talk together about patients (i.e., “everyone communicating about patients,” “lots of brains are on it at once,” “everybody will bring up different suggestions or thoughts from their own experiences,” “all constantly sharing situations where we don't know what we are doing”). Sometimes CC involves additional patient factors including social situations, difficult transportation, and insurance issues.

Differentiating curbside consultation from formal consultation … “A second set of eyes”

Nurse practitioners differentiated CC from FC. Curbside consultation is categorically more of a courtesy communication or coordination of care. When referring a patient, NPs will call to let a clinician know about the patient, reason for referral, and measures already taken. Some PCNPs will curbside consult an expert before referring to initiate care during the FC wait period or to notify specialists about patients should the need for FC occur.

Sometimes CC is considered as coordination of care between established providers of specialty and primary care. Specialist experts consult on mutual patients managed in primary care to verify plans or receive reassurance concerning a condition managed by both clinicians. In the inpatient setting, SNPs will contact established specialists to coordinate discharge planning or provide updates to care.

In some cases, a colleague will come into a patient room for “a look,” “hands on the patient,” “a second set of eyes,” and “take a quick peek at the patient” and this is still considered CC. Sometimes CCs are not even about patients or from practitioner colleagues. Family members will ask about a nonpatient family member, or a nonpatient staff member will ask for health care advice. Nurse practitioners used CC daily, multiple times per day, or multiple times per week.

Advantages and disadvantages of curbside consultation… “CC enriches your practice regardless of what you do with it”

When asked about advantages and disadvantages, some reported that there were no disadvantages. Other would acknowledge some limitations to the process; nevertheless, CC is positively viewed. Curbside consultation was seen as having a net positive: “more advantage than disadvantage” or “more advantageous than not.” There are benefits to the individual clinician, the patient, the institution, health care system, and society. “CC enriches your practice regardless of what you do with it” (Outpatient Family Practice FNP 13 years). There were multiple positive descriptions of CC as liked or loved.

Learning … “Helps me think and gets my own gears going”

Curbside consultation is seen as a wonderful tool and viable part of the practice, resulting in learning, feedback, validation, and developing rapport with coworkers. Curbside consultation is seen as a learning experience from the standpoint of being the seeker and the expert. One NP referred to her role as the expert in CC as “expands your own knowledge” and “helps me think and gets my own gears going. It is … it's fun … I like “nerding out” (Outpatient Endocrinology/Gastroenterology [GI] FNP 12 years).

I learn on both ends. Because you can learn more from a systems approach, you can learn how hard it is that the community care NP's have to work to navigate that one patient through. You also learn how many times a patient has been bounced back between the emergency department (ED) … and then over to primary care, and then over to us when they literally never needed to see all … of those people. Right? (Outpatient Orthopedic FNP 7 years).

Patients are comfortable seeing their primary care provider … “(CC) can save them time … energy, resources, and they can help their patients better”

Curbside consultation is helpful for the primary care clinician and sometimes for the experts as well. Curbside consultation helps the primary care provider (PCP) who wants to take care of patients in the best way possible, keeps things in-house, and helps patients take control of their lives. Primary care providers see many patients every day and deal with more problems in a shorter time. “(CC) can save them time … energy, resources, and they can help their patients better” (Outpatient Orthopedic FNP 5 years). However, a specialty NP stated, “some PCPs see doing CC as more work because the PCP can't just dump the patient off with a specialist … Instead of throwing them in line, why don't you ask us for help, and there may be stuff you can do without sending them to us” (Outpatient Orthopedic FNP 5 years). Helping PCPs and patients navigate the system improves access to care because there is typically a long waitlist to see a specialist. Patients often express comfort in seeing PCPs. Curbside consultation helps people get care faster where they are most comfortable.

Curbside consultation versus formal consultation “I don't think you need to see the patient”

In the inpatient setting, it is beneficial for the expert to curbside consult as opposed to FC. Nurse practitioner providers with past inpatient setting experience relate that some specialists would rather do CC, and for some, FC “makes them upset.” An NP expresses her thoughts on trying to obtain FC in the ED as annoying and brutal, with many instances of specialists resistant to FC (Outpatient Women's Health FNP 19 years). Another inpatient NP mentioned often prefacing questions with “I don't think you need to see the patient” (Internal Medicine FNP 3 years). This NP expressed that experts are often pleased to hear this.

In addition, a musculoskeletal SNP reports that CC is helpful because “then I don't have to see unnecessary patients in my clinic” (Outpatient Orthopedic FNP 5 years). A gastrointestinal SNP states that CC “reduces the burden to the specialty system with things that are much more garden-variety” (Outpatient GI FNP 12 years). A specialty general surgery NP mentioned CC can avoid “clogging up patient care when formally refer” and described patients running all over town to see different specialties unnecessarily (Outpatient General Surgery FNP 1.5 years). Avoiding inappropriate referrals allowed SNPs to see patients who truly needed to see specialists and saved time and energy. Nurse practitioners see CC resulting in better, prompt patient care and an opportunity for both the seeker and the expert to help an individual. Curbside consultation is seen as extremely beneficial and valuable for patients. “Hey rather than sending to GI for irritable bowel syndrome (IBS), how about you do these tests? Let's confirm it's IBS and then you can move it to our team” (Outpatient GI FNP 12 years).

Several NPs understood that value-based care includes CC by decreasing unnecessary use of resources by providing information to PCPs or patient themselves without formally referring them. Curbside consultations in turn decrease appointments and referrals, ED visits, school and work absences, and money spent. Specialists are able to provide recommendations without completing a full history and physical examination, laboratories, or imaging in FC.

Collegiality and collaboration “I got your back”

Curbside consultation is beneficial for promoting collegiality and collaboration, connecting with other colleagues, and expanding the professional network. “Being there, knowing people, getting more exposure affects your credibility” (Outpatient Orthopedic FNP 5 years). A true advantage to the CC is the ability of colleagues to collaborate “without having to add more hands into the mix” (Outpatient Family Practice FNP, 13 years). In other words, the original provider may be able manage the patient condition, avoiding FC for the patient. Some NPs look forward to the opportunity to connect with other colleagues in the community.

Curbside consultation for the institution is seen as promoting a team atmosphere and strengthening our community. One NP stated, “I got your back” (Outpatient GI FNP 12 years). Allocation of knowledge across the institution, having multiple opinions and different points of view, is instrumental in the delivery of comprehensive care. Promoting CC internally is better for the institution and allows things to keep running smoothly internally and externally, “increasing communication with the community, awareness, collegiality, so good networking” (Outpatient Women's Health Women's Health Nurse Practitioner [WHNP] 24 years).

Some NPs found it difficult to extrapolate the impact of CC on the health care system and society; however, most felt that CC decreases costs and improves efficiency. “(CC) reduces time, reduces costs. It doesn't clog up the system so then the system can be safer for more serious cases” (Outpatient GI FNP 12 years). When clinicians are able to collaborate and share knowledge, the result is better healthcare. “(CC is a) benefit to society because in the end it provides better care” (Outpatient Women's Health WHNP 24 years). “CC helps patients, institution, health care system and society” (Outpatient Family Practice FNP 5 years).

On the other hand, there are some overt disadvantages to CC. For instance, there was concern about burdening or interrupting another colleague and that it is time consuming for both parties, perhaps even delaying clinic processes. In some settings, CC is not an option because an expert is inaccessible or declines to respond in a timely manner.

Both the seeker and the expert are responsible for accurate communication. The seeker must relay an accurate and complete history. If this does not occur, communication is not appropriate and expert recommendations are erred. The seeker may get “bad advice” based on anecdotal experience or may disagree with advice. If the seeker's judgment of expertise is not accurate and does not validate advice with evidence, suboptimal patient care occurs.

Expert recommendations are unofficial. The expert may be missing valuable information, may mishear information, is not able to see the patient, watch them move, and cannot put their hands on them. Overall perceptions were that experts are able to get enough of the story to ask about red flags.

The expert does not generate revenue, and a lack of financial incentive is a burden to the process. Perceived legal implications of the lack of documentation with CC as opposed to FC particularly when negative patient outcomes occur is a concern. Last, patient information provided without direct permission is a concern particularly when patient identifiers are used.

Professional duty … “If someone needs help to take care of a patient, you're gonna help them…”

Nurse practitioners viewed participation in CC as a professional duty. Only two believed that CC is considered collegial albeit not a duty. Curbside consultation is not a component of job descriptions.

It doesn't say you must provide FCs to colleagues from other disciplines, but I think it's kind of an unspoken rule. Like, you're in health care and why are you here? To help people. If someone needs help to take care of a patient, you're gonna help them (Outpatient General Surgery FNP 1.5 years).

Nurse practitioners perceived CC as a way to advocate and help one other or pay it back. There is reciprocity and appreciation, as well as loyalty to the profession. Nurse practitioners will help one another in anticipation of needing help themselves. Nurse practitioners work hard to help inexperienced NPs to promote the profession, encourage growth, and acknowledge that NPs work better together than alone. Curbside consultation is due diligence, part of the job, and necessary for NPs to be there for each other in order to be there for the patients. One SNP perceived a professional duty. “Because medicine is kind of a shared occupation. It's not just one person is silent and has all of the information and that everybody else doesn't. I think it's a shared communal practice” (Outpatient Women's Health WHNP 24 years).

Documenting the curbside consultation … “Throwing someone under the bus”

The difference between PCNPs and SNPs concerned documentation. “I always chart, it’s important” (Outpatient Family Practice FNP 4 years), “Do not want to throw colleagues under the bus” (Outpatient Family Practice FNP 13 years) “If I sign the chart … shows that I thought that” (Outpatient Family Practice FNP 13 years). Specialty Nurse Practitioners felt that CC documentation is strongly discouraged saying that doing so makes it a FC. Curbside consultation without officially consulting did not hold any weight or liability because the expert had no ownership of that patient. Curbside consultation is inherently informal or unofficial and does not warrant documentation. “Documenting the CC … I would never do that” (Inpatient ICU ACNP 5 years). Typically, expert NPs do not plainly ask if the seeker NP is going to document. SNPs report they do not think that experts consulted would want advice documented. There were reservations about documenting, “(I) spoke to so and so, NP and they told me xyz,” with concern for their interpretation being different (Outpatient Pediatric Pediatric Nurse Practitioner [PNP] 4.5 years).

However, when consulting with supervising physician (MD), some SNPs felt it is worth documenting. Specialty Nurse Practitioners will document “okay to treat per so, and so” (Outpatient Oncology FNP 18 years) and will sometimes write as an order. Intrinsic to the NP being first a nurse and wearing many hats, one NP reported that she will sometimes act in more of a supportive role and felt that it is more important to document the MD's advice. One SNP relates, “will document it as a mid-level practitioner” (Outpatient GI FNP 12 years), whereas another will write “had conversation with MD collaborative, plan developed” (Outpatient General Surgery FNP 1.5 years). This is relayed as partial justification for their decision-making.

Legal liability … “At the end of the day … my decision”

Legal liability is considered by most NPs to be inbuilt within their practice. NPs are more often unsure of the legal implications specific to CC. Some report that there is legal liability in participating in CC, and some even say there is legal liability in not participating in CC. One SNP answers, “Probably (legal liability). Do I worry about that? Nope” (Outpatient orthopedic FNP 5 years and Outpatient Women's Health WHNP 24 years). Some perceived liability for both parties, whereas the majority felt liability is only for NP managing the patient directly. Experts are not liable for giving advice and are only liable when Health Insurance Portability and Accountability Act is mismanaged. “At the end of the day, (it is) my decision at the end that really matters from a legal standpoint” (Inpatient Internal Medicine FNP 3 years). Consideration for collaborative practice agreements and necessity to include the supervising MD in case of emergency or outside of NP's scope of practice existed. “Be safe and cover your ass all the time” (Outpatient Family Practice FNP 13 years). Nurse practitioners felt patient care decisions were more defensible when naming MDs in charting. An inpatient SNP significantly changed CC practice subsequent to attendance at a legal seminar and now views CC legal liability as higher than FC (Inpatient Cardiovascular FNP 8 years). “There is always a liability in everything that we do, or don't do” (Inpatient ICU ACNP 5 years).

Unspoken rules … “Ask the right questions …”

Nurse practitioners reported no explicit rules for CC, yet many admitted some unspoken rules or norms existed. First, ask the right questions, consider appropriateness, and be organized and prepared. It is acceptable and appropriate if it is a simple or easy question. It is considered inappropriate if there is a complicated clinical picture or multipart questions about a specific patient. One NP specified, “No more than three parts to a question … it is unfair to the expert to hear the whole story from beginning to end, or to expect help on urgent requests. “If you want a formal consult, don't expect it to be done today” (Outpatient General Surgery FNP 1.5 years). Another SNP requests when emailing to allow at least 24 hours for responding (Outpatient Orthopedic FNP 5 years). It is preferable to have a clear question at the end of presentation, some formation of recommendation or plan, and present with solutions, not problems. The seeker needs organization and provides quick and accurate history and good understanding of what they need. Having specific, formulated, coherent, and complete presentation with all pertinent information ready is optimal. Key quotations when discussing rules: “with all ducks in a row,” “cut the crap,” “use as few words as possible … mindless questions drive me crazy,” “being organized and prepared and having pertinent information already loaded into your mind and your presentation, so that the curbside can go quickly and smoothly.”

If it's more complicated–If I have more than three parts to a question for you, I am not going to ask for a CC. You need to get paid for your time. That's crazy. If it's simple, I feel okay about it (Outpatient Pediatrics PNP 11 years).

Next, maintain patient confidentiality, be respectful and considerate, and use the information received in CC with caution. Nurse practitioners advise not to take personally, be careful to not come across as patronizing, condescending, or discouraging, choose words carefully to make it as meaningful as possible, and make sure not stepping on anyone's toes. If you don't agree with the advice, don't say “Well, that was really dumb. That didn't help me at all. Thanks for nothing, but goodbye” (Outpatient Women's Health WHNP 24 years). Some state that fewer rules and regulations make better and more inviting CC. Uniformly, being considerate and respectful of expert time is fundamental. Make it easy on the expert by not dumping work on them. Do not abuse CC on a personal level (i.e., contacting the expert too many times) or depend on CC as the sole information source in clinical decision-making. There is personal loss if a provider uses CC too often and others may question expertise. “You have to put on your big girl panties and make your own decisions” (Outpatient Women's Health FNP 19 years).

Patient-centered in choosing an expert … “Show me they are really looking out for the patient's best interest …”

The patient's unique situation and preferences are key underlying considerations for NPs in patient management. Nurse practitioners are deliberate in choosing experts that understand patients holistically and are considerate of patient needs. Experts should care about socioeconomic factors such as patient costs and ability to afford treatments. Ideally, experts are respectful, kind, and proactive about involvement in care and have reputations for clinical appropriateness and positive patient outcomes. Experts are willing to do what is best for the patient subsequent to consideration of financial gain. “Show me they are really looking out for the patient's best interest, all other things aside” (Outpatient Orthopedic FNP 5 years).

Patient engagement “Talked with Dr. so and so …”

Nurse practitioners often inform patients regarding the needs for CC and agreement or disagreement with recommendations. When NPs are unsuccessful in contacting experts, the patient receives updates concerning delays, that is, “Will get back to you, have the medical assistant call you back later.” “Talked with Dr. so and so told me to do “abc” and come back in 6 weeks…we are both on the same page” (Outpatient Pediatrics PNP 11 years).

Nurse practitioners consider patient perspectives and preferences and intend transparency when giving patient options. Some nurse practitioners include patients during the CC. For example, a NP will invite the expert to a patient room. “Here is the situation. Here are your options. Let's talk about which one might be best for you” (Outpatient Women's Health FNP 19 years).

Nurse practitioner perceptions of patient perception of CC is mostly positive. Nurse practitioners believe patients appreciate CC and experience reassurance. Patients see NPs as taking an extra step or being interested enough to optimize care. Nurse practitioners reflect on multiple opinions or different points of view, fill their knowledge gaps, and provide optimal care. Nurse practitioners believe patients perceive CCs as valuable.

Discussion

Curbside consultation is a common phenomenon. Nurse practitioners in our study participate in CC frequently and value expertise. Nurse practitioners consider CC as a real-life way of receiving information or feedback. Curbside consultation is quick and convenient and offers collaboration and back-and-forth conversations. Curbside consultation is not binary, rather appearing to occur on a spectrum from formal to informal. Curbside consultation involves coordination of care in addition to advice seeking. There was a lack of consensus on boundaries of CC including difficulty in distinguishing CC from FC. The inconsistencies found in the CC definition identifies a need for further exploration of this patient care decision-making process.

Nurse practitioners perceive multiple advantages and disadvantages of CC. Nurse practitioners worry about burdening colleagues, and occasionally, CC is not an option if an expert is unavailable and inaccessible or declines to respond. Curbside consultation can also be time consuming and requires all parties to handle information exchange with care. If communication is inaccurately portrayed, patient care error may occur. There is financial loss to experts, and legal implications may ensue. Although there were no formal rules mentioned, there are several unspoken rules for NPs participating in CC.

Curbside consultation is collegial and expands primary care clinical management. Some NPs see CC as a component of value-based care. Curbside consultation is a means for collaboration for reduction in unnecessary resource use and improvement in primary care. Nurse practitioners consider patient perspectives and preferences and attempt to be transparent when providing patient options. Nurse practitioners perceive CC to be of value from the patient perspective. Curbside consultation fosters a unique social support and bidirectional communication resource that does not occur when using static resources such as a textbooks or the literature to address a patient care question. In addition, because NPs continue to grow in their role of the frontline providers in patient-centered medical neighborhoods, CC is an important aspect of cultivating effective communication and promoting evidence-based practice, collegial relationships, and institutional climate required to provide harmonized care.

Study limitations are inherent in the methodology and small sample size from a relatively homogenous geographic location. Generalizability is limited. The study site has a restricted practice environment, as opposed to full or reduced practice environments. Strengths include rigorous qualitative methods and review of key literature to identify missing themes.

Conclusion

Health information needs for decision-making is an important concern among NPs regarding patient outcomes. Curbside consultation is a preferred information source for NPs in this study. Curbside consultation among NPs is not described extensively in the literature. This study provides an initial assessment concerning NP involvement in CC and its perceived impact on patient care. This study represents an initial understanding of CC for NPs. Given the potentially substantial impact of CC on patient care, further assessment is obligatory.

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Keywords:

Clinical decision-making; collaboration; curbside consultation; nurse practitioners

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