Response to "Nurse Practitioner-Patient Discourse: Uncovering the Voice of Nursing in Primary Care Practice"
Brykczynski, Karen A. Rnc, Fnp, DNSc, Scholarly Inquiry for Nursing Practice
Advocacy of a central role for nurse practitioners as primary care providers in ambulatory care is based on the belief that nurse practitioners can make a potentially significant contribution to primary health care in terms of cost containment, humanization of health care delivery, quality and comprehensiveness of services, and alternatives for consumer choice. The ability of nurse practitioners to offer something unique that impacts on outcomes in primary care (Sullivan, 1982) may be partially understood by the smaller social class differential between nurse practitioners and patients, increased emphasis on explanation, and greater agreement between the illness realities perceived by nurse practitioners and patients (Kleinman, Eisenberg, & Good, 1978). Johnson's qualitative research seeks to illuminate how nurse practitioners attend to contextual and situational aspects in nurse patient encounters and contributes to understanding the elusive process of care.
UNIQUE CONTRIBUTION OF NURSE PRACTITIONERS
In her study of nurse practitioner-patient conversations to enhance understanding of how the knowledge and skills of nursing and medicine coexist and are actualized in the practice of nurse practitioners, Johnson identifies and describes the voice of nursing in primary care. These hybrid nurses (nurse practitioners) who incorporate medical components into the nursing perspective can be understood as bicultural and bilingual. They are fluent in the voice of medicine and the voice of patients (the lifeworld). Their role as translator or liaison between patients and physicians is thereby legitimized.
Johnson's study supports many of the findings from my study of nurse practitioner practice (Brykczynski, 1985, 1989). Deeper understanding of the unique contribution of nurse practitioners and some direction for further investigation can be gleaned from discussion of the findings from both studies. This response is organized using the framework of the four major activities of the office visit or encounter. First, the agenda is established. In Johnson's study there is evidence that the agenda is negotiated jointly by the nurse practitioner and the patient. This supports the egalitarian, collaborative, partnership mode of relationship commonly favored by the nurse practitioners in the study I conducted.
Next,the history is elicited. There is some evidence that nurse practitioners are particularly skilled in history taking. During the history-taking component of the encounter, nurse practitioners in Johnson's study were observed to: 1) attend to the patient's lifeworld, 2) be alert to subtle cues, and 3) act as a sounding board. These aspects support the theme of "assessment expertise" (Brykczynski, 1985) wherein assessment expertise was observed to involve: 1) spending time with patients, 2) focused listening, and 3) the recognition of subtle cues. In addition, the skill involved in attending to the patient's lifeworld reflects the competency "detecting acute and chronic disease while attending to the experience of illness."
Then during the physical exam component of the visit, nurse practitioners in Johnson's study were reported to: 1) attend to both the patient's physical and psychological comfort and 2) intersperse teaching into the exam process. These findings were frequently noted during the participant observations in my previous work. An additional observation that may be worthy of further investigation is that patients often comment that they rarely have such thorough and complete physical exams as when nurse practitioners perform them.
The fourth and final activity, developing apian of care incorporates diagnostic studies, recommended treatments, patient education, and followup. During the plan component of the encounter, Johnson observed that nurse practitioners made use of the teachable moment and personalized solutions for patients. These findings support activities characteristic of several competencies including "maximizing the patient's participation and control in his/her own health/illness care" and "selecting and recommending appropriate diagnostic and therapetuic interventions and regimens with attention to safety, cost, invasiveness, simplicity, acceptability, and efficacy (Brykczynski, 1985). …