Nurse Practitioners and the Performance of Professional Competency

Accomplishing Patient-centered Care

Staci Defibaugh

• Publisher: Palgrave Macmillan
• Year: 2017
• ISBN:
  9783319683546
• Topic: Languages & Linguistics
• Subtopic: Linguistics
• Index: Languages & Linguistics

This book examines the interactional practices of nurse practitioners (NPs) and the delivery of health care in the US. The author takes a discourse analytic approach, examining the linguistic resources that NPs employ in their interactions with patients. These linguistic features are connected to the concept of professional competency with specific focus on the enactment of the patient-centered approach. Analytic focus is placed on how NPs address organizational responsibilities during medical visits with patients, the form and function of patient education, the use of indirect speech, and the role that small talk plays in health care encounters. The book explores the understudied professional field of nurse practitioners and examines their linguistic practices with an eye on crossing disciplinary boundaries, integrating research from linguistics, discourse analysis and health communication. It will appeal to those interested in medical discourse analysis and health communication, as well as applied linguistics scholars.

© The Author(s) 2018

Staci DefibaughNurse Practitioners and the Performance of Professional CompetencyCommunicating in Professions and Organizationshttps://doi.org/10.1007/978-3-319-68354-6_1

Begin Abstract

1. Introduction

Staci Defibaugh¹

(1)

English, Old Dominion University, Norfolk, VA, USA

Abstract

Healthcare visits with nurse practitioners (NPs) are becoming more common in the United States. Despite their growing numbers, we know little about NPs’ interactional practices. This book addresses this gap in the literature by providing a discourse analytic account of NP–patient interactions. In this introductory chapter, prior research on NPs’ effectiveness as healthcare providers lays the groundwork for the analytical chapters which follow. The book considers how NPs’ interactional practices align with the concept of professional ‘competency’; therefore, a discussion of how ‘competency’ is defined in terms of effective communication and its link to positive health outcomes and patient satisfaction is discussed. The chapter concludes with a discussion of the research context and a brief description of the remaining chapters.

Keywords

Nurse practitionersPatient satisfactionHealth outcomesCompetencyPatient-centered care

End Abstract

1 Introduction

The primary goal of this book is to present an analysis of the interactional practices of nurse practitioners (NPs) during medical visits with patients. The approach I take, which is to examine the particular linguistic choices that NPs employ, addresses an important gap in the research as the majority of discourse-based studies of medical interactions have focused almost exclusively on medical doctors (MDs). However, as healthcare delivery in the United States continues to shift, NPs are becoming more prominent figures in health care. Therefore, understanding their interactional practices and situating those practices within the context of their educational and training background as well as the prior research on their effectiveness are essential. Not only are NP–patient visits becoming the norm in the United States, because of their educational background in nursing and their patient-centered, holistic approach, NPs represent a new power dynamic (Defibaugh, 2014a) and one that must be explored more fully in order to present an accurate portrait of provider–patient visits in the United States.

This introductory chapter provides a theoretical and empirical grounding for the analytic chapters that follow. As such, I provide background on NPs as a provider type, including information on their educational background and training, the role that they play in US health care, and the existing research on NPs’ effectiveness in terms of patient satisfaction and health outcomes. I also operationalize the concept of ‘professional competency’ by drawing on prior research in health communication and the way that competencies are defined by various medical accreditation boards. The chapter concludes with a description of the data that will be drawn on in subsequent chapters, including descriptions of the clinical sites and background information on the NPs that participated in the study.

2 Nurse Practitioners: A Growing Presence in US Health Care

NPs are a subgroup of Advanced Practice Registered Nurses (APRN), who work in a variety of settings and specialties, including primary care, emergency, oncology, and women’s health. NPs typically hold either an MS in Nursing (MSN) or Doctor of Nursing Practice (DNP) degree, which requires an additional two to four years of full-time education beyond the four-year RN degree (Explore Health Careers, 2013) as well as 500–700 supervised clinical hours (Iglehart, 2013). NPs are licensed by the individual states in which they practice and must pass a national certification exam (AANP, 2017). Similar to medical doctors (MDs), NPs may specialize in their degree programs and can seek employment in a variety of inpatient and outpatient settings. Reports indicate that approximately 93–94% of NPs are female (US Department of Health and Human Services, 2014; Skilman, Kaplan, Fordyce, McMenamin, & Doescher, 2012).

The number of nurse practitioners practicing in the United States has been steadily increasing over the past two decades. The American Association of Nurse Practitioners (AANP) states that there were over 220,000 licensed NPs in the United States as of 2016, with numbers projected to increase to 244,000 by 2025 (AANP, 2017). The steady increase reflects the greater presence that NPs have in health care in the United States. One trend in health care that may partially account for the growing number of NPs is the current shortage of primary care physicians , particularly felt in rural areas and inner cities where physicians are less likely to practice (Goodell, Dower, & O’Neil, 2011). With only about 30% of all US physicians practicing in primary care, an amount totaling approximately 200,000 primary care physicians (National Center for Health Care Statistics, 2011), many areas are underserved. Bodenheimer and Pham (2010) report that many people live in areas where the ratio of patients to primary care providers is approximately 2000 to 1. The AANP statistics note that only 14.5% of physicians entered a primary care residency in 2016, again highlighting the continuously low numbers of MDs practicing in primary care and the increased need for alternative providers such as NPs to fill this gap. Auerbach et al. (2013) project that by 2025, physicians will represent only about 60% of all primary care providers—a drop of 11% from where they were in 2013, when the data were reported. They suggest that the ratio of MDs to NPs in primary care will be 2:1, respectively (Auerbach et al., 2013). In the Veterans Affairs (VA) system, NPs currently make up approximately 20% of all primary care visits and fulfill similar roles as MDs (Morgan, Abbott, McNeil, & Fisher, 2012).

As NPs are taking a more prominent role in healthcare delivery in the United States, many states are also changing regulations, allowing for greater NP autonomy (Gadbois, Miller, Tyler, & Intrator, 2015). As of 2016, NPs have prescriptive privileges in all 50 states and the District of Columbia, and according to the AANP, 95.8% of practicing NPs prescribe medications. Twenty-six states in the United States allow NPs to practice autonomously. The research collected for this book was conducted in Indiana and Illinois. In these two states, NPs may be designated as primary care providers (PCPs); at the time of data collection, both Illinois and Indiana required what is known as ‘physician oversight’ (Barton Associates, 2017), a somewhat vague term that refers to some level of supervision by or coordination with an MD. What this means in practice varies and is often dependent on the organization and/or physician (personal communication). Gadbois et al. (2015) similarly note that while some states make explicit the regulations for practice of NPs and physician assistants (PAs) , many states use vague language making it difficult to determine what the scope of practice for NPs and PAs actually is. In the VA system, the site of the outpatient visits included in this book, NPs see patients independently but have a coordinating physician who reviews their charts biweekly and provides guidance when questions arise. The NP in this study working at a community hospital also sees patients independently but works with a team of physicians , none of which ‘oversee’ her practice but coordinate care with her.

The shift in the make-up of health care, particularly in primary care, has led to an increased presence of NPs and an expansion of their scope of practice in many states. As health care continues to change in the United States from a primarily doctor-centered culture to one that includes other provider types such as NPs or PAs, nurse practitioner–patient interactions are an important and under-researched area of study, which can provide insight into the new medical model of healthcare delivery, which takes a more holistic and patient-centered perspective. As the following section notes, NPs have a presence in US health care for decades, and their training and focus on patient-centered care has already been well documented in the literature; however, the fine-grained linguistic analysis of these interactions is an area that deserves more attention as it can provide a more comprehensive understanding of the language used in healthcare delivery in the United States today.

3 Nurse Practitioners: Prior Research

3.1 Nurse Practitioner–Patient Interactions

Although discourse and conversation analysts have been studying doctor–patient interactions since the 1970s, very little research has focused on nurse practitioners. While Sally Candlin’s (c.f. 2000, 2010) work on nurse–patient interactions comes the closest to providing a systematic account of how the occupation of nursing is constructed in medical interactions, her research focuses on registered nurses (RNs), rather than NPs, a role with a very different position within the medical community and a different context for interaction. In my own work on nurse practitioner–patient visits, I have noted the ways in which NPs seek to create solidarity with patients by minimizing the inherent asymmetry of the medical visits through the use of indirect speech (Defibaugh, 2014b) and aligning with patients’ narrative experiences (Defibaugh, 2014a); however, these two studies alone do not provide the type of comprehensive account of NP–patient interactions that this book contributes.

Two earlier discourse-based studies offered a comparison of NPs with other providers (Drass, 1988; ...

Table of contents

• Cover
• Front Matter
• 1. Introduction
• 2. Frontstage/Backstage: Attending to Organizational Responsibilities
• 3. Need to Know: Patient Education and Epistemic Responsibility
• 4. Treading Lightly: Indirect Speech in Medical Directives
• 5. Caring as Competent: Small Talk in Medical Visits
• 6. Conclusion
• Erratum to: Nurse Practitioners and the Performance of Professional Competency: Accomplishing Patient-centered Care
• Back Matter