Dr Hilary Paniagua

1. A study comparing the consultation practice of Advanced Nurse Practitioners and General Practitioners in Primary Care Dr Hilary Paniagua

2. Aims • To find out what ANPs do • What is advanced practice

3. Design of the study • ANPs and GPs worked together doing the same roles • Training practice within an urban general practice in the West Midlands • Emergency surgeries of 2 ANPs with MSc in Advanced Practice and 2 GPs

4. Chosen methodology • Capture natural occurring talk by video recording GP and ANP emergency consultations • Structuralist and poststructuralist linguistic philosophy that are access to reality is through language. • Words are considered to be how individuals experience themselves and others within the world, and how these experiences are interpreted

6. Transcript D2. 3 Consultation with GP and elderly patient with angina001 P3: look I (2.0) can’t get me breath when I start walking002 DA: right (patient prods at his chest)003 P3: and the (2.0) I have to be walking (1.0) pains004 DA: ­you’re getting pains005 P3: yeah006 DA: when you’re walking are [you007 P3: [it’s not a pain its tightness =008 DA: = right =009 P3: right010 DA: how long has that been going on [ for now?011 P3: [it’s gradually come on for about the last three 012 P3 weeks it’s just getting worse and worse like013 DA: ok014 P3: yeah015 DA: are you breathless every time you’re walking016 P3: yeah I am017 DA: or is it just in [certain conditions018 P3 [no I am now [like when I first started it was just (2) I walked yer 019 DA: [ok020 P3: know cos I walk quite a bit like (1) I’ve had a bypass021 DA: [right022 P3: [as I walk[023 DA [now (2) have you had angina pain before (1) given

7. Transcript A2. 1-2 Consultation with ANP and patient who wants to talk 001 P2 I can’t really say you’re going to help me but I wanted to talk to you about it = 002 Su: = that’s fine= 003 P2: = I haven’t sort of felt right for weeks you know [ just sort feel its not going 004 Su: [mumm 005 P2: away this ache and this feeling that I’ve got I’m not just right and I felt my arms kind of 006 P2: itching now today I haven’t felt it but everyday I’m scratching at my arms the back of my 007 P2: neck remember when I had that bad fall on the a bus remember at X = 008 Su: = yes yes = 009 P2: = now they said I had a crack ah crack in my head and I had a break in my collar bone yes 010 P2: that’s right = 011 Su: = yes that’s right = 012 P2: = now honestly sometimes when I turn my head and I’ve got my hair looks like up the back so 013 P2: often will it wear off that’s what I wanted to say 014 Su: how long ago now was that? 015 P2: it’s about seven months [eight months ago[ June it was 016 Su: [yeah [mumm 017 Su: I wonder if you’ve got perhaps a little bit of arthritis in the back of your neck as well 018 Su: perhaps it’s exaggerated it a little bit = 019 P2: = oh do you think so? 020 Su: don’t know we’ll have a look at you 021 P2: so well that’s a (.)[ 022 Su: [now when did the irritation start = 023 P2: = it’s just itching I feel like scratching my neck to sometime and and this arm mind you did I 024 P2: tell you about three weeks ago I had a a car knocked me down 025 Su: ohh dear = 026 P2: = everything happens at once but all my life I’ve never had anything up until two years ago 027 P2: and I’ve three things [one after the other in two years 028 Su: [mumm 029 Su: and how did your road traffic accident happen 030 P2: well I was crossing the road, not at the crossing needless to say, but you know going along X 031 P2: road to X, [ lights were stopped at X road, [so I knew there was nothing coming at the next 032 Su: [mumm [mumm 033 P2: stop after that the crossing, the stop, so the next car I could see was way past the school 034 P2: there, you know, and it was belting along. I tho I’ll make that easy cos I’m quite a quick 035 P2: walker you know, and I was about that much off the pavement, now this is, that’s the truth, 036 P2: about that much off the pavement, he says he didn’t see me can you imagine? I was crossing 037 P2: the road, no no traffic coming that way and he said he didn’t see me, and I said well you 038 P2: shouldn’t be driving if you didn’t see me, well anyhow to cut a long story short, he he 039 P2: swerved he put his brakes on he swerved to the centre, well of course the next car coming (leans fast forward) 040 P2: along so fast he came at me, the next car came at me you know and knocked me and I sort of 041 P2: myself lying just like exactly like I’ve shown you (11 lines missing about GP) 053 P2: after that I just wanted to talk to you about it what do you think 054 Su: um I’m sure he’s right may I have a little look at you shall I? (consultation proceeds to a full examination)

8. ANPs had a different relationship with patients • Patients interacted more with ANPs because: a) ANPs worked to diminish social distance with patients b) Patients were always aware of what nurses were thinking and why they did things as they used online thinking (voice of nursing) c) ANPs worked within a medical framework yet interweaved their nursing skills within this (medico-nursing world)

9. The medico-nursing world/the ‘voice of nursing’ 150 Sz: I’ll just get you some a leaflet (2.0) there are different 151 types of worms but the most common is the little tiny thread worm[ which 152 M: [right ANP turns to face mother 153 Sz: is what you they um (1) I’ve got twins and um when the one of them was 154 six months old she actually passed a round worm which is like a white 155 earth worm and the only way she’d have picked that up was from dogs or 156 and we didn’t have any so I don’t know whether the previous owners of the 157 house had a dog and she’d been crawling in the garden and I mean I nearly 158 died because this thing was [like six inches long and even though I’m medical 159 M: [ohh no 160 Sz I’d never seen something so I couldn’t quite work out what 161 M oh no and the fact it was coming from your own child you see 162 Sz: um

10. ANPs used the strategy of thinking aloud and ‘on-line’ 119 Su: ok um what could we put (.) it’s such a difficult spot isn’t it right on your eyelid = 120 P2: = yes 121 Su: normally I say use a bit of hydrocortisone which you can if you are extremely extremely 122 careful = 123 P2: = yeah 124 Su: um if Claritin normally works that’s fine we could change your antihistamines = 125 P2: = um = 126 Su: = and try something different 127 P2: well I had some Zertec on holiday cos I had a reaction to my suntan lotion = 128 Su: = it’s an odd set up right 129 P2: but it I don’t know whether it was but I taking I took the first one at about 11 o’clock when 130 P2: I started [to itch with this rash and then by about 4 o’clock I was zonked and they made me 131 feel 132 Su: [yes 133 P2: a bit sick 134 Su: right so so stick to the Claritin then

11. No verbal diagnosis 091 Sz: I can’t um find anything dramatic on your chest 092 P2: no oh that’s something 093 Sz: um and it’s one of those situations where isn’t it? where I am sure if you leave it long enough it 094 Sz: would go away of its own accord = 095 P2: = yeah = 096 Sz: but the fact that you’re feeling a bit tight 097 P2: yeah (tilts head backwards and strokes throat) 098 Sz: it may very well be that at night that because your nose is blocked when you lie down it drips to 099 Sz: the back of your throat[ 100 P2: [mum[ (makes a sweeping motion with both arms upwards backwards and forwards) 101 Sz: [rather than actually it being a chest infection but I can see 102 Sz: from the type of person that you’re not a great attender 103 P2: no (14 lines ANP checking the infrequent history of visits) 117 Sz: yeah no so I am quite happy to give you a week’s supply of an antibiotic because of that 118 P2: thank you very much

12. Ideas on Advanced Practice • Involves the response created with patients • Creating partnerships • Seen in the voice of nursing • Is the creation of a medic-nursing world • Involves strategies such as online thinking

13. THANK YOU!