Comparison of GP and nurse practitioner consultations: an observational study

Analysis

Audiotapes were transcribed and nurse or GP utterances were coded (using QSR NVIVO software) according to a category scheme derived in part from the concerns of the literature review, and in part inductively from the data. The categories are arranged into groups that identify significant generalised behaviours. These, apart from the ‘social/emotional/patient-centred’ generalised category, whose elements can occur at various stages, describe well-recognised phases of many primary care consultations. For example, our study of general practice consultations for children's upper respiratory tract infections identified a routine pattern.12 Information gathering exchanges are generally followed by a physical examination, at the end of which the condition is usually named and explained. Treatment recommendations then follow, with arrangements for these being made. Within each of these phases, particular things occur that are described in the more detailed coding categories exemplified in Table 2.

The coding scheme was developed by all three authors. Initial coding was done by one investigator. Each coding decision was then separately inspected by a second investigator and any differences resolved. NVIVO allows highlighted text passages to be coded (like a word processor), unlike other programmes that require whole lines or sentences as coding units. This means character counts (as in Table 3) as well as counts of coded passages (as in Table 4) are good indicators of the amount of emphasis placed on particular topics. Additionally, the overall length of each consultation was recorded in seconds (see Table 3). t-tests were used to compare means of the two groups (measured in utterances, letter characters or seconds). Although somewhat controversial,13 the Bonferroni correction has been applied to multiple comparisons shown in Tables 4 and 5 to provide a more demanding level of significance and thereby correct for the phenomenon of accepting some differences as significant when they have only arisen by chance because of multiple testing.

Summary of main findings

We have found that the content of consultations by nurse practitioners was somewhat different from those of GPs when seeing similar ‘same day’ patients. Both patients and clinicians spoke more in nurse consultations. In consultations that were longer than those of doctors, nurses talked significantly more than doctors about treatments and, within this, talked significantly more about how to apply or carry out treatments. Weaker evidence was found for differences in the direction of nurses being more likely to: discuss social and emotional aspects of patients' lives; discuss the likely course of the patient's condition and side effects of treatments; and to use humour.

Predictably, given the limited autonomy of nurse practitioners,4 references to the arrangements for signing prescriptions and approvals of a treatment plan were almost exclusively the preserve of nurses. In several cases, nurse consultations ‘ended’ at that point as the nurses switched the tape recorder off and both parties left the room. If the time taken up by carrying out these arrangements were to be added to the overall times recorded in Table 4, the lengthier nurse practitioner consultations would be lengthier still.

Strengths and limitations of the study

The limitations of this study include its focus on ‘same day’ clinics in primary care and it is therefore likely to be skewed towards acute, self-limiting illness. Other primary care consultations where nurse practitioners are involved, or hospital settings, might reveal different patterns of interaction. Furthermore as nurse practitioners gain confidence and experience in their role they may adjust their behaviour in consultations. The small number of consultations and practices studied may limit generalisability. Against this, the study provides precise, detailed descriptions of different patterns of interaction, enabling clinicians to recognise familiar behaviours and judge the relevance for their own practice.

Comparison with existing literature

This is the first observational study, as far as we are aware, to compare the content of consultations by nurse practitioners and GPs consulting with patients with urgent problems in the NHS. Our findings are consistent with the only other comparative observational study we have been able to find,10 concerning North American nurse practitioners who were found to spend more time discussing psychosocial issues than physicians. They are consistent with studies based on patients' reports of the content of consultations, which have suggested that nurse practitioners give more information to patients8 and more advice on self care and management.8^,9 The differences that have been identified in these studies and the present study may explain differences in levels of satisfaction revealed in other research.7

Implications for clinical practice.

Implications depend on which of two potential explanations are preferred, and these are not mutually exclusive.

Firstly, differential status between the two types of clinician and their patients may influence behaviour. The medical role is regarded as more prestigious in wider society and social distance between doctors and patients is likely to be greater than between nurses and patients, perhaps leading to nurse practitioners and their patients feeling more relaxed about raising and discussing a broader set of concerns.

Secondly, GPs may have a different perspective on the conduct of ‘same day’ clinics in primary care, where the priority is to deal efficiently with patients’ presenting complaints. They may view such work as ‘extra’ to the usual clinical workload and treat it differently. The nurse practitioners' lengthier approach may reflect both differences in their initial training and in the relative novelty of the role, seeing these consultations as an interesting opportunity to demonstrate newly acquired clinical independence and thus deliver unusually high quality care. Unlike GPs, perhaps, they may not distinguish ‘same day’ clinic work from other clinical settings in which a more holistic approach might be considered more appropriate by GPs.

At present, economic and health outcome evaluations suggest no significant differences between nurse practitioners and GPs, suggesting that the extra things done by the nurses may not contribute to clinical effectiveness. To raise satisfaction, but possibly negatively affect the cost balance, GPs might consider adopting some of the behaviours of the nurse practitioners that this study describes. Nurse practitioners, on the other hand, may consider the cost savings that might be achieved were they to adopt the (more efficient but apparently less satisfying) GP approach. Alternatively, the money spent on the time taken by the nurses getting prescriptions signed by GPs might be saved in a system that afforded nurse practitioners greater clinical autonomy, although the potential risks of this to clinical outcomes and the allocation of legal responsibility for these risks would require careful assessment.