Decision-making and communication practices of nurse practitioners in primary care settings: An ethnographic study

How nurse practitioners (NPs) specifically contribute to clinical, quality, and cost outcomes (American Academy of Nurse Practitioners, 1994) and the distinguishing elements unique to their practices (Stanford, 1987) are not well understood. The aims of this ethnographic study were to (a) describe decision-making (DM) and communication practices (CPs) of NPs and (b) contribute to theory identifying the unique practice characteristics of NPs. Two research questions guided the study: (1) Are there defining characteristics of NPs' DM and CPs during clinical practice? (2) How do NPs' DM and CPs contribute to interactions with patients in the clinical setting?; This study used a purposeful sample of 11 NPs in 6 primary healthcare clinics. Data were divided into units, coded, and categorized while constant comparative and language analysis techniques were applied. While DM by NPs is largely eclectic, clearly NPs make greater use of pattern recognition than hypothetico-deductive DM. DM attended to the patient's contextual issues, allowed actual and potential issues into the conversation, demonstrated a lack of preoccupation with biomedical causes alone, and was greatly concerned with effects of disease and health promotion. Uncertainty emerged as a DM context with NPs consistently in pursuit of information to reduce uncertainty for themselves and their patients.; The CPs of NPs unified the languages of medicine and care. NPs used terminology and defmed health and health practices in terms that mattered most to the patient. NPs reinforced the importance of the patient's perspective by providing ample time for, by initiating discussion about, and by seeking to resolve the patient's contextual issues thus contributing to personal bonding with patients. NPs created the perception for their patients that patients' input is the primary determinant of the trajectory and breadth of communications.; NPs reinforced therapeutic understanding with verbal and non-verbal communications by maintaining certainty during speech, staying on topic by gently redirecting conversation, speaking with therapeutic purpose, changing emotional tone to reinforce understanding and to elicit patient response, maintaining personal proximity, using movements that have specific verbal meaning in lieu of speech, using emotional expression to reinforce and validate patient feelings, and using illustrators to reinforce expression.