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Qualitative Research

Impact of nurse practitioner care on patients with chronic conditions

Dusseldorp, Loes van MSc (Researcher)1; Groot, Marieke PhD (Senior Researcher and Assistant Professor)1; Adriaansen, Marian PhD (Professor)2; Vught, Anneke van PhD (Associate Professor)2; Vissers, Kris PhD (Professor)1; Peters, Jeroen PhD (Program Director)2

Author Information
Journal of the American Association of Nurse Practitioners: September 2021 - Volume 33 - Issue 9 - p 728-738
doi: 10.1097/JXX.0000000000000438

Abstract

Introduction

Background

The nurse practitioner (NP) acts at the intersection of care and cure. According to the Canadian Medical Education Directions for Specialists (CanMEDS) framework, the NP's tasks and responsibilities stem from seven core competencies: Clinical Expertise, Communication, Collaboration, Organization, Health Advocacy, Science, and Professionality (ter Maten-Speksnijder et al., 2014; Frank et al, 2015; Kappert & de Hoop, 2019). In daily practice, NPs fulfill various roles—depending on the work setting, clinical discipline, collaboration with physicians, and the organizational policy regarding task allocation and professional development (ter Maten-Speksnijder et al., 2014). Overall, patients highly value the care provided by an NP and may be even more satisfied with the care provided by an NP than that provided by a physician (ter Maten-Speksnijder et al., 2014; van Hezewijk et al., 2011; Festen et al., 2008; Laurant et al., 2008; Broers et al., 2006). From a quantitative perspective, patients appreciate an NP information provision on prognosis and recovery, time available for consultation, accessibility, communication skills, and information and support on coping with the disease (Broers et al., 2006; Laurant et al., 2008; van Hezewijk et al., 2011). Patients receiving treatment from an NP perceive a high quality of life (ter Maten-Speksnijder et al., 2014; van Hezewijk et al., 2011; Festen et al., 2008; Laurant et al., 2008; Broers et al., 2006). Because none of the above-mentioned studies gives full insight into the underlying experiences of patients, we previously conducted a qualitative study from a phenomenological perspective (van Dusseldorp et al., 2019). We explored what meaning outpatients receiving oncological or palliative care associate with the treatment and support provided by an NP. We concluded that the participants perceived this as reliable, helpful, and empathic. However, these participants were facing a life-threatening illness and therefore were a specific population. The question remained whether the findings can be transferred to patients with a non–life-threatening disease such a chronic heart failure (CHF) and inflammatory bowel disease (IBD).

Method

Aim

To describe the difference in perception of NP care by patients suffering from CHF or IBD in contrast with NP oncological or palliative care.

Design

To be able to compare the findings of the previous study with this study, we used an identical qualitative design, method of sampling, selection, data collection, and data analysis (see van Dusseldorp et al., 2019). This study also adhered to the consolidated criteria for reporting qualitative research guidelines (Tong et al., 2007). See Supplemental Digital Content 1 (http://links.lww.com/JAANP/A53). In this method section, we describe only additional aspects or specific steps.

Sampling and selection procedure

To explore the breadth of nursing and medical care in a population for whom next to quality of life, managing symptoms and coping with a chronic disease are pivotal, we recruited patients being in a CHF or IBD outpatient trajectory supervised by an NP, in the same three hospitals as in the previous study (patients with CHF in the first NYHA stages were included, they were therefore not in a palliative care trajectory).

Candidate participants were invited for an interview by their NPs (10 NPs in total) and received an information sheet on the study.

Data collection

Data were collected between July 2018 and March 2019. The same interview guide as in the previous study was used. To get familiar with problems and needs of the study population, the principal investigator (L.v.D.) explored additional literature regarding living with a chronic disease. Each interview consisted of three parts (Figure 1). For details, see van Dusseldorp et al., (2019).

Figure 1.
Figure 1.:
Flow diagram showing proceedings in the three parts of the in-depth interviews.

Research team

The research team and the steering board had remained unchanged over time. The interviews were conducted by Loes van Dusseldorp, a nurse (np) and a nurse scientist.

Ethical considerations

This study was assessed by the Medical Research Ethics Committee, which concluded that it did not fall within the remit of the Dutch Medical Research Involving Human Subjects Act. Review by the CMO-light procedure based on the Dutch Code of conduct for health research, the Dutch Code of conduct for responsible use, the Dutch Personal Data Protection, and the Medical Treatment Agreement act was judged positive (file number 2018-4440). Again, the study protocol was also approved by the ethics review boards of the two other participating hospitals.

Data analysis

The “complete study”—that is, the previous and present studies together—uses a phenomenological and interpretive research paradigm. For analyzing the data, we built on the code framework that had emerged from the previous study. Participants of the previous study are indicated as ID 01–ID 17; participants of this study as ID 18–ID 33. All data were analyzed using Colaizzi's seven-step method (Polit & Beck, 2012), including an additional step to analyze the metaphors (Edward & Welch, 2011) (Tables 1 and 2).

Table 1. - Colaizzi's seven-step method with an additional step (Polit & Beck, 2012; Edward & Welch, 2011)
Colaizzi's Seven-Step Method of Phenomenological Enquiry With an Additional Step
1. Transcribing all the participants' descriptions
2. Extracting significant statements, i.e., statements that directly relate to the phenomenon under investigation
3. Formulating meanings for each significant statement
4. Organizing formulated meanings into clusters or themes
5. Integrating results into exhaustive description of the phenomenon;
6. Additional step—interpretative analysis of symbolic representations
7. Identifying the fundamental structure of the phenomenon
8. Returning to the participants for validation of the findings

Table 2. - Four steps of the Metaphor Identification Procedure (MIP) (Pragglejazz Group, 2007)
Four Steps of the Metaphor Identification Procedure (MIP)
1. Read the entire text discourse to establish a general understanding of the meaning
2. Determine the lexical units in the text discourse
3. (a) For each lexical unit in the text, establish its meaning in the context; that is, how it applies to an entity, relation, or attribute in the situation evoked by the text (contextual meaning).
(b) For each lexical unit, determine if it has a more basic contemporary meaning in other contexts than the one in the given context. For our purposes, basic meanings tend to be more concrete (what they evoke is easier to imagine, see, hear, smell, and taste); related to bodily action; more precise (as opposed to vague); and historically older.
(c) If the lexical unit has a more basic current-contemporary meaning in other contexts than the given context, decide whether the contextual meaning contrasts with the basic meaning but can be understood in comparison with it.
4. If yes, mark the lexical unit as metaphorical

Computer software Atlas.ti version 7.1.5. and version 8.3.20, respectively, was used to manage the data. This did not change the analyses or results.

Rigour

To assure trustworthiness of the data analysis, the same procedures as used in the previous study were used; that is: anonymous transcription; thick description; field notes; peer review; debriefing; and a member check (Polit & Beck, 2012). Data saturation in this study was reached after having analyzed 15 fully transcribed interviews. One more interview was held to confirm the preliminary findings or find deviating data.

All participants were invited to perform a member check on an overview table containing quotes, emerged meanings, themes, and fundamental themes. Seven participants accepted the invitation and validated the findings. No adjustment of important aspects was necessary.

Results

Characteristics of the participants

In the complete study, 33 persons with a mean age of 60.5 years (range 20–82) were interviewed. The patient population in this study (Table 3) was on average 6 years younger than that in the previous study (57.4 vs. 63.9 years). In contrast to an equal gender distribution in the previous study, the patient population in this study consisted mostly of women. The onset of the disease differed in the two populations. Although in the previous study for most participants the time passed since diagnosis varied from 1 to 5 years, in this study, this varied from less than 2 years (37.5%) to more than 11 years (37.5%). For all participants, contact with the NP was mostly on a regular basis when visiting the outpatient clinic, sometimes by phone or email. The frequency of the contact for all participants varied from once every 2–3 weeks to once every 6 months.

Table 3. - Participant characteristics study 2 (ID 18–33)
Sample Characteristics (N = 16) N %
Gender
 Female 11 68.75
 Male 5 31.25
Age in years
 Mean (range) 57.4 (20–82)
Marital status
 Married 1 6.25
 Married with children 9 56.25
 Single* 3 18.75
 Single with children 3 18.75
Diagnosis
 Heart failure 8 50
 Coronary microvascular dysfunction 1 6.25
 Crohn's disease 5 31.2
 Crohn's colitis 1 6.25
 Ulcerative colitis 1 6.25
Time passed since diagnosis
 <2 years 6 37.5
 3–5 years 3 18.75
 6–10 years 1 6.25
 >11 years 6 37.5
Note: Single*: this marital status encompasses: never been married, divorced, and being widow(er). Some of the single participants were living apart or together with a new partner at the time of the interview.

Fundamental themes

Analysis of the 16 interviews in this study confirmed the six fundamental themes that had emerged in the previous study:

  1. The NP as a human.
  2. The NP as a professional.
  3. The NP providing care.
  4. The NP providing cure.
  5. NPs organizing patient care.
  6. Impact on the patient's wellbeing.

The interviews with the CHF and IBD patients revealed a different emphasis on NP care than did the interviews with the patients in the previous study dealing with a life-threatening disease. Because CHF and IBD are non–life-threatening, these participants were more concerned with the physical limitations of the chronic disease and with the emotional issues that can affect their own and their loved ones lives. Hence, the meanings CHF and IBD patients associate with their experiences had a different emotional undertone than that of the patients in the previous study. Consequently, a new theme cluster, “Improvement of perceived health,” emerged as a component of the sixth fundamental theme. The majority of the formulated meanings accorded with the previously identified meanings. We added several specific meanings expressed by the CHF and IBD patients.

Table 4 contains the comprehensive thematic map on fundamental themes and theme clusters; the added and emphasized items that emerged in this study are formatted in italics.

Table 4. - Thematic map of emerged fundamental themes and theme clusters, total
Fundamental Themes Theme Clusters Examples of Formulated Meanings
The NP as a human Empathic
Helpful
Reliable
Let you feel welcome, would like to talk with youProvides personal attention
Shows willingness to help, is helpful
Feels familiar, expresses confidence and reliabilityProvides more personal contact
The NP as a professional Coach
Expert/authority
Supporter
Patient's advocate
Acts like a sounding board, is a coach, advises
Has medical expertise, knows comparable situations
Has attention for the complete picture
Is back up in someone's situation
Holds up a mirror
Brainstorming together, on equal level.
Reciprocity and collaboration
Is aware of and transparent about professional boundaries
Has attention to one's spouse
Possesses sensitivity/antennae/feelers
Can be relied on
The NP providing care Discussing the treatment
Advising
Keeps a finger on the pulse
Gives advice about medication and side effects
Training/teaching the patient new skills e.g. injecting medication
Advices and supports healthy lifestyle
The NP providing cure Monitoring
Discussing test results
Monitors (abnormal) blood values, discusses results of scans
Carries out physical checks
The NP organizing patient care Coordination
Collaboration with other professional care givers
Coordinates between other therapists
Contacts ASAP the medical specialist, if necessary
Is the connection in the hospital
Takes initiative for further physical tests
Is easy accessible and approachable by phone or email
Ensures continuity of care
NP and medical specialist work as/form a duo.
Impact of the NP on patient's wellbeing Empowerment
Peace and calmness
Being in control of one's disease and the consequences
Personal attention
Improvement of perceived health
Helps to achieve personal goals
Provides rest, confidence, and takes away fear
Helps with coping
Focuses on quality of life
Supports restoring life-work-illness balance.
Increases medication compliance
Encourages to raise the alarm sooner
Note: NP, nurse practitioner.

The NP as a human

For this fundamental theme, the existing theme clusters were confirmed and therefore apply for the complete study population, namely: 1) the NP as an empathic, 2) helpful, and 3) reliable person. As for being empathic, the fact that the NP makes you feel welcome, is happy to talk with you, shows understanding, and provides special attention meant a great deal to participants. For CHF and IBD patients, the personal contact was also highly valued and considered important.

“… The second-to-last time we visited, we talked about holidays, telling that we had been on holiday and then he about his holiday also.” (ID 23)

In line with the previous study, participants in this study experienced of connection and familiarity with the NP.

“A kind of aunt. Yeah, but it is really nice with her. I can ask her, 'why don't you have kids,' you know? It's not a doctor, there's no distance.” (ID27)

Some participants in this study also put forward that their NPs show willingness to help, express confidence, and reliability.

“… Well, that makes me feel reassured. If I have an issue and then tell him [NP] and he knows how to reassure me, then it's good for me too. I really believe in him.” (ID23)

The NP as a professional

Within this fundamental theme, the four theme clusters were confirmed: 1) coach; 2) expert; 3) supporter; and 4) patients' advocate. For all participants, the NP represented a coach who coaches, advises, and serves as a sounding board. The interviewed CHF and IBD patients find it important, too, that the NP holds up a mirror, as it were, as a means to reflect on one's behavior in coping with the disease.

“That encourages you to think about it for yourself. …But still it's wise to also do that in a one-on-one relationship with a nurse specialist, and I find it nice that there's a response there.” (ID29)

Another valued aspect of the NP functioning as a coach is brainstorming on an equal level. Therefore, the professional relation is perceived as a mutual relation.

“That's never how it is with the NPs. They discuss it. …You can work that out. Just ask something and you'll get an answer and you know then how to proceed.” (ID31)

All participants highly value and appreciate the NP's (medical) expertise—but also highly value the knowledge of the medical specialist (MS). Because the NP has experience, insight, understanding, and has seen many comparable situations, she is just as the MS seen as an authority. Expressions like “She does have all the knowledge of all variants, all the treatments, all the possibilities, complications, and what else have you got. … This is what she has as a background, which makes her an expert partner to talk with.” (ID02), and “She was able to give answers in such an appropriate manner. Knows about things, about medicine. Yeah, gives an explanation in a nice way.” (ID22), illustrate the meaning of these experiences.

The appreciation of the NP being aware of and transparent about her professional boundaries emerged particularly in this study.

“And if she has any ideas. When she says, 'I'm thinking about this, but I have to discuss it with the cardiologist.' Well, a day later it turns out that she [the NP] is right. Then I think, yeah, she's a real pro.” (ID22)

For all participants in the compete study, the NP represents a supporter who heeds the complete picture and offers physical and mental support. The CHF and IBD patients explicitly added the interest in one's partner.

Apart from this, participants described several situations in which the NP is seen as a professional and is appreciated for being the patient's advocate. For participants in this study, it additionally means a lot that the NP is sensitive in anticipating someone's story or doubts.

“Actually, such a nurse [NP] is the 'extension' of the cardiologist, because they are the feelers that protrude where all the data comes in.” (ID26).

Some participants in this study add value to the fact that they could rely on the NP for questions and urgent matter. As one of them put it: “She knows me by now. … And that means that if I have an issue or if I think about something, I can always contact her.” (ID28)

Nevertheless, certain aspects in the communication with the NP were found missing. For instance, one participant in an oncological trajectory (ID01) did not share his emotions or grief with his NP. He kept these issues private, and the NP did not raise such issues. Another participant in an early stage of IBD (ID21) reflected on the intake session and realized she missed a clear explanation of her diagnosis.

The NP providing care

Underlying themes within this fundamental theme are conclusive for the complete study population: 1) discussing the treatment and 2) advising the patient.

The meanings patients associate with discussing the treatment with the NP show similarities with the previous study. One participant with CHF told how the NP and she had discussed stop taking medication or reduce the dosage because of the side effects:

“I'm having a lot of dizzy spells. … The NP asks every time, 'Is it bearable?' I say, 'Yes, it is, but every time I get up and I don't think about it,… you get it again. It's just very annoying.' So,… asked in advance, 'Can't I do away with certain medicines? …because all that junk in my body.' The NP says, 'No, those drugs keep you alive'.” (ID23)

The NPs in this study were, like their colleagues in the previous study, also appreciated for answering questions about medication or teaching new skills, for example, inject medication. However, the NP advising and supporting a healthy lifestyle frequently emerged additionally as an important aspect of providing care.

“They said that I just had abdominal pain—that it was just all in my head, the pain. And with that she helped me quite a bit, like, 'You have to listen to yourself as well. It's not just in your head'. 'Sometimes your body says you need some rest and then you indeed need to take a rest'.” (ID20)

The NP providing cure

Identical theme clusters emerged within this fundamental theme: 1) monitoring and 2) discussing test results. All participants pictured the NP as checking blood values and monitoring abnormal blood values, and carrying out physical checks. Two participants said:

“She always does check, too, yes. Just check it. … Yes, all lymph … After all, I recently also had a bump like that here … It is still a bit red. … Then she also says: 'Probably already for some time.' (ID05) And, 'Weighing and measuring. And the heart rate. Making a ECG, that's where she starts'.” (ID23)

The NPs who provide CHF and IBD care also discuss test results of, for example, ECG or possibly abnormal blood values and consequences. As one participant (CHF) put it: “If she gives the result of the blood. Or what the doctor has said. And then she calls back about it and always right on time. You can set your clock by it. … I don't care but I am… and then she tells me if something needs to be changed.” (ID19)

The NP organizing patient care

Within this fundamental theme, the two identified theme clusters seemed conclusive for the complete study population, namely: 1) coordination and 2) collaboration with other professional care givers. Although patients in this study associated similar meanings to the NP's coordination of patient care as those in the previous study, most of the participants in this study emphasized the high level of accessibility of the NP—especially in an early disease stage or when urgent inflammations occurred.

“But if I had something in between, I could send her an email and she usually reacted very quickly. And if there was something really urgent, I could just call her.” (ID20)

Participants described several situations in which the NP takes the initiative for collaborating with the MS or other professionals in case of medical, physical, mental, social, or practical problems. Several patients in this study told how the NP and MS work together as a duo, something they highly appreciate.

“So I have a doctor and NP and those two treat me and know everything about me, and not that you are referred to this person or that person, but that it really is just the two of them.” (ID 20)

Participants in this study—in general—did not miss any essential issues concerning this theme cluster. Just one participant (IBD) would have appreciated a visit of her NP when being admitted in the hospital due to an inflammation.

Impact of the NP on patient's wellbeing

The four theme clusters identified during the previous study were confirmed: 1) empowerment; 2) peace and calmness; 3) being in control of one's disease and the consequences; and 4) personal attention. Additional insights from the CHF and IBD patients showed a fifth theme cluster: “Improvement of perceived health” (see also Table 4).

All interviews revealed that the NP was of great help and made one feel more empowered by the guidance, treatment, and support. In general, the NP enables coping with the disease as well as with the impact of the disease in daily life and helps to set goals to regain one's own life. Feeling empowered differs in detail with the type of management. Where empowerment for participants facing a life-threatening illness means dealing with questions about life and death, the empowerment when being chronically ill is rather focused on self-efficacy. The NP stimulates reflection on one's physical condition or playing an active role in one's disease or healing process. As ID29 (IBD) illustrated: “It motivates you to think about it for yourself. …. more to deal with it in a different way. I didn't have that before. That was actually a resigned situation. …. Now I'm working on it a lot more myself. In a positive sense.”

Although participants in this study do not experience their illness as life-threatening, contact with the NP brings peace and calmness for them as well. The possibility to share concerns about an inflammation or contact the NP by telephone in case of urgent questions has a reassuring and soothing effect.

“It's someone you can fall back on. Well, that gives you a lot of relief. … I never called her, you know… But the idea that you could call is nice. … That's very important, that you have a little rest during the day.” (ID32)

All participants made clear that contact with the NP makes them feel in control of the disease and its consequences for daily life activities. In addition to providing clarity about, for example, pain management, the NP specialized in CHF or IBD advises on nutrition or the hazards of tourist attractions in relation to an implantable cardioverter-defibrillator. Regarding personal attention, all NPs in the complete study pay attention to quality of life and personal background. Patients feel understood and being seen as more than “just a number.”

“The NP likes details and also direct personal guidance. It is as if she looks through you, as if she has known you for years. … A cardiologist, has, you can feel it, many more patients. She does too, but she's dealing with a patient individually.” (ID24)

“Improvement of perceived health” emerged as an additional theme cluster in this study. Participants experienced the impact of the NP on their wellbeing by restoring the life-work-illness balance, increasing medication compliance, and raising the alarm sooner when noting worsening symptoms.

“The balance is back a bit more. That is not yet complete. I also expect that it won't come all the way back. … What I'm saying, then it's on that level, the nursing specialist is a huge added value. Those [the hobbies] I can just do again.” (ID29)

Metaphors

Five emerged metaphors were confirmed in this study. Only the metaphor of the NP symbolizing a technician was not identified. Each of the five metaphors is described below.

The NP means trust

Most frequently one described how the relationship with the NP is based on trust. Participants in the complete study have confidence in the NP's expertise and associate the NP with a warm nest and a sympathetic ear. Additional meanings describe the NP as a really close friend, a favorite aunt with a sympathetic ear, a key to openness, family, “together,” and having a warm heart.

One person (IBD) described it this way: “The key belongs with the lock. If the key does not fit in the lock, nothing will open.that I also open up to her, that you can be yourself.” (ID31)

Another participant (CHF) said: “…a kind of confidant. I think that sounds rather distant, butan aunt with an lending ear. Something like that?(ID27)

The NP is a travel aid

In this metaphor, the NP was depersonalized into a lifebuoy sign. The NP is accessible in times of need, in case of (medical) problems or for answering urgent questions. The trust in the NP's expertise is valued as comforting when one feels upset or drifting. One participant (IBD) said: I just float a bit through my life and sometimes it goes very fast. Then you just have something to hold on to so you can look around for a while. And thinking, we'll have to go that way later on. Instead of it sinking away completely and the disease taking over. Then the NP is something I can hold on to.” (ID28)

Another, less frequently used, metaphorical expression was the outlet. ID24 (CHF) who came up with this metaphor described it this way: “The direct outlet. For me, it blocks at moments when I can't overlook it. If I can overlook it then it goes well, but if I can't overlook it then the NP is the first valve.”

The NP is a combat unit

In contrast with the previous study, only one patient with IBD used this metaphor. She visualized her collaboration with the NP as a “fight against the disease.” The NP is like a partner in rafting, someone with whom she fights to beat IBD.

The NP is a link

Although in the previous study, many participants used this metaphor, only two participants in this study came up with this metaphor. The NP is a vital link to connect the chain of their illness; the NP is a bridge between the patient and the MS, and the NP is a circle.

“I'd think, put it in a circle. If I have something, she starts working on it. She tells me that again and it always stays nicely round, that circle. So that it never shoots out of the curve. It makes you stay calm throughout.” (ID20)

The NP is a signpost

This metaphor of guidance and support signified yet another aspect of the NP as experienced by a few participants. Some of them felt lost and caught by the disease, just like participants in the previous study. The NP picks up the signals, steers them in the right direction and guides them to cope with the disease in daily life: “That you are taken by the hand to consult togetherFor me it is indeed the hand that leads me” (ID31).

Symbolic representation by association pictures

Of the 45 association pictures, two of the three most selected ones were similar with those selected in the previous study, although with a slightly different meaning, namely: 1) Two people holding hands, associated with “sense of trust, doing it together, the NP taking in hand” (5×); and 2) rafting in wild water, representing “teamwork, determine the course together” (2×). The third and different picture selected by participants in this study was 3) two fingers pointing at one document, associated with “find out what's going on together, trust each other” (2×) (Figures 2–4).

Figure 2.
Figure 2.:
“Sense of trust, doing it together, the NP taking in hand.”
Figure 3.
Figure 3.:
“Teamwork, determined the course together.”
Figure 4.
Figure 4.:
“Find out what's going on together, trust each other.”

Discussion

We found that patients receiving CHF or IBD versus those receiving oncological or palliative care suggest both highly appreciate the NP for six fundamental issues: 1) being a human, showing empathy, helpfulness, and reliability; 2) being a professional, with the key roles of coach, expert, supporter, and patient's advocate; 3) providing care, with discussing the treatment, and advising; 4) providing cure, with monitoring and discussing test results; 5) organizing care, with coordination and collaboration with other professional caregivers; and 6) having impact on wellbeing; that is, feeling more empowered, in peace, calm, and in control of the disease, receiving personal attention, and improved perceived health as a new, additional theme.

The findings from the complete study are in line with the literature reporting that patients overall are satisfied and well appreciate the care of NPs (ter Maten-Speksnijder et al., 2014; van Hezewijk et al., 2011; Festen et al., 2008; Laurant et al., 2008; Broers et al., 2006). In these quantitative-oriented studies, technical aspects and concepts such as accessibility, information regarding prognosis and recovery, and interpersonal aspects were assessed with Likert scales. In our study, however, the interpersonal aspects of the NP's care and the impact of these aspects on patients' wellbeing were studied in-depth. Therefore, our overall findings additionally provide a unique qualitative insight in the underlying meaning patients associate with the NP.

The meanings from both studies show more similarities than differences. The cores of the attached meanings seemed the same, although the chronic versus the life-threatening aspect of the illness created some nuances. The communicator role of the NP, however, emerged as the most paramount role. Some key concepts of this role, one of the seven CanMEDS core competencies for NPs, are: “active listening”; “attention to psychosocial aspects of illness”; “empathy”; “mutual understanding”; “patient-centered approach to communication”; “shared decision making”; and “trust” (Frank et al, 2015). Participants' meanings are reflected in these key concepts. Although one may suggest that the tasks and responsibilities of the NP are self-evident, the integration of the knowledge, skills, and attitude seems to give color and meaning to the task performance.

The meanings identified in the complete study (Table 4) suggest that in general, the NP acts on the intersection of cure and care; with attention to physical, social, psychosocial, and existential needs. This seems to connect well to Dierckx de Casterlé's concept of “skilled companionship” (Dierckx de Casterlé, 2015). The harmonious integration of a high level of competency and a caring attitude is the key characteristic of what is known as third-level care, driven by this skilled companionship. This implies that a patient feels supported by the empathic presence of an NP. Patients feel that NPs understand what they are going through and what this means for them. This multidimensional approach seems conclusive for patients in the complete study. Participants facing problems associated with life-threatening or chronic physical conditions have special care needs (Beesley et al, 2018; Lee Mortensen et al, 2018; Moore et al, 2014; Seah et al, 2015). The NPs in our studies connect to these care needs and thereby realize skilled companionship. In all, this results in attention to the patient's “complete picture,” which is key in oncological and palliative care, as well as in CHF and IBD care.

In the Netherlands, the NPs have the professional competence for independently prescribing medication by virtue of the Individual Healthcare Professions Act [Wet BIG] (Dutch Ministry of Health, Welfare and Sport, 2019). Most participants were not aware of this, and it seemed not important to them. They highly appreciate the NP for consulting the MS in case of medication issues. Trust in the NP's expertise increases by the NP being transparent of this collaboration.

Limitations

Because of the (relatively) small sample size, one may question the transferability of the complete study. In qualitative research, a sample size of 33 participants is a significant amount. Although additional quantitative data might strengthen the emerged evidence, we believe that the findings of the total study can be transferred to NP's providing outpatient somatic health care in the Netherlands. Second, our results could have been positively influenced by the NPs' drive to contribute to the further development of their profession. This may have led to some selection bias, either in a positive direction (recruiting motivated patients with high appreciation for the NP) or an unknown direction (patients with less ability to reflect might not have been selected). To minimize these potential biases, Loes van Dusseldorp encouraged the NPs to recruit participants based on the inclusion criteria and thereby take into account patients who dare to be critical. Despite these limitations, the qualitative findings importantly add to the body of knowledge on NPs' roles and practices. The rigor of the data collection (with diversity among patients) and data analysis and the applied steps and methodologies strengthen the value of the achieved insight.

Conclusion

To our knowledge, these are the first studies exploring in depth what meaning patients associate with the treatment and support by an NP in somatic health care. Although the perspective of having a chronic disease differs from that of having a life-threatening disease, backup and support from the NP is valued as reliable, helpful, and empathic. Patients felt empowered, at peace and in control thanks to the NP's support, guidance, and personal attention. Receiving integrated care at expert level made them feel safe and embraced.

Implications for practice

Outpatients in somatic health care highly appreciate the “communicator role” and “skilled companionship” to fulfill their needs for attention to the “complete picture.” Therefore, reflection on these competencies in the curricula of the Master of Advanced Nursing Practice programs is recommended, for example, by providing tools to improve or develop these skills. Also, attention must be paid in education to develop awareness that patients appreciate the working relationship and attitude of the NP apparently more than just clinical reasoning or medical knowledge. Furthermore, addressing these issues in the (compulsory) peer-to-peer coaching after graduation is recommended. This might contribute consolidating the NPs' position. On the organizational level, our findings can be helpful in selecting suitable candidates for vacancies. Participants in the complete study faced problems associated with life-threatening illness and chronic physical conditions. Future research should therefore explore patients' view on the care provided by NPs in other domains, for example, mental health care or primary care.

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Keywords:

Life-threatening illness and chronic disease; nurse practitioner; phenomenological perspective

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