Nurse practitioner and physician communication styles

Original Articles Nurse Practitioner and Physician Communication Styles Marjorie Thomas Lawson

No empirical studies of nurse-patient relationships have focused on interpersonal communication and its effects on patient outcomes. In this study, 124 provider-patient interactions of five nurse practitioners (NPs) and four physicians (PHYs) were audiotaped. Communication patterns were examined Io determine whelher Ihe practilioner's predominant slyle was informational or con trolling and whether style affected patient satisfaction and perceived autonomy support. All providers used predominantly informational styles of communication. Significant differences in communication styles existed between provider groups (F 5.90, dJ' 1/8, p .05) and among individual providers (F 4.28, dj' 8/123, p < .0001). All providers were more controlling in their communication patterns when attempting to make decisions and plan patient care. Examination of communicalion slyles can help NPs develop the skills necessary to provide patient centered care. Copyright 2002, Elsevier Science (USA). All rights' reserved.

OMMUNICATION SKILLS that focus on patient individuality, understanding, attentiveness, sharing of information, and genuineness are frequently reported to be among the most sought-after qualities of nurse practitioners (NPs) (Drury, Greenfield, Stilwell, & Hull, 1988). However, little research has examined NP communications with patients or compared them with physician (PHY) communications. In an early study, communication styles of NPs and PHYs in joint practice were compared (Campbell, Mauksch, Neikirk, & Hosokawa, 1990), and few differences were found. However, NPs showed more psychosocial concern than PHYs when interacting with

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Marjorie Thomas Lawson, PhD, RN CS, FNR Associate Pro¢~,ssor (~' Nursing~Family Nurse Practitioner, Universit3, of Southern Maine, College o1" Nursing and Heahh Prqfessions, Portland, ME. Address reprint requests' to Marjorie Thomas Lawson, PhD, RN CS, FNP, Associate Prqfi, ssor o/" Nursing~Family Nurse Practitioner, Universi(v of Southern Maine, College of Nursing & Health PngOssions, PO Box 9300, 96 Falmouth St, Portland, ME 04104-9300. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0897 1897/02/1502 0002535.00/0 doi: 10.1053/apn ~2002.29522 60

patients. In a more recent study, Courtney and Rice (1997) focused on NP teaching activities (providing advice, facts, and explanations) and patients' perceptions of NPs' communication. Skills in communication that encourage client problem-solving and client participation in the healthcare process appeared lacking. Clearly, in the current healthcare climate, it is important for providers to support client participation in self-care. More positive communication may enhance an individual's motivation and autonomy and promote learning and positive health behaviors. Deci's theory of self-determination (Deci, 1980) provides a useful framework for examining provider communication. Based on the assumption that human beings have three psychological needs: competency, autonomy, and relatedness (Deci & Ryan, 1985), the self-determination theory distinguishes between the motivational dynamics underlying activities that people do freely and those that they feel coerced or pressured to do. The theory suggests that meaningful feedback promotes selfdetermination in any situation in which competence information is relevant. However, information promotes self-determination only if it is presented in the context of support for autonomy, Applied Nursing Research, Vol. 15, No. 2 (May), 2002: pp 60-66

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i.e., in an informational style. Information presented in the context of pressure to think, feel, or behave in stipulated ways toward specified outcomes without benefit o f negotiation or choice is viewed as controlling. In one o f the few studies to examine autonomy support in a healthcare context, attendance and program completion were linked to staff's autonomy support for individuals attending a supervised weight-loss program (Williams, Grow, Freedman, Ryan, & Deci, 1996). Williams and Deci (1996) also found that second-year medical students who perceived their instructors as more supportive of autonomy showed more self-initiation in their learning. Also, investigators who studied patient satisfaction have found that when PHYs adopted a communicative style that is informational (being attentive, answering questions, soliciting opinions), patients expressed more overall satisfaction (Roter et al., 1997). Conversely, when PHYs showed a more controlling communication style (absence of explanation, giving directions/commands, predominance of provider talk), patients' evaluation were less favorable (Hall, Milburn, Roter, & Daltroy, 1998). However, no studies have looked at patient satisfaction with NPs from this perspective. Also, the research to date on provider communication has been conducted almost exclusively in the context o f initial or episodic encounters, although more than 80% of provider-patient communications occur in the context of established relationships. This study therefore investigated NP and PHY communication styles and their relationship to perceived support for autonomy and patient satisfaction within the context of established provider-patient relationships. METHOD

Setting and Sample This descriptive-correlational study examined the communication styles of five NPs and four second- and third-year medical residents (PHYs) to determine whether the practitioner's predominant style was informational or controlling and whether style affected patient satisfaction and perceived support of autonomy. Data were collected in the adult ambulatory medical clinic of a large tertiary referral center in northern New England that serves

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as a clinical site for the education o f NPs and medical residents.

Providers NPs were eligible if they had practiced a minimum of 1 year after completion of their practitioner program and a minimum o f 6 months in the current setting. PHYs were eligible if they were second- or third-year residents and had practiced a minimum of 6 months in the current setting. The experience criteria ensured sufficient opportunity for the providers to develop their predominant communication style and follow patients in the context of ongoing relationships. Three full-time and two part-time NPs, all women, participated. Three PHYs were men, and one PHY was a woman. Average ages of NPs and PHYs were 41.4 and 30.3 years, respectively. NPs had been in practice an average of 9 years, with an average of 6.8 years in the current setting. PHYs had been in practice an average of 3 years, with an average of 2 years in the current setting.

Patients Patients who met the following inclusion criteria were eligible: (1) older than 18 years, (2) able to read and write English, (3) alert and oriented, (4) having an established relationship with one of the nine providers (i.e., a minimum of two previous visits within the past 12 months), and (5) being seen for a return visit regarding an ongoing nonemergency nonacute physical condition. A total of 151 qualified patients were approached in the waiting room before their visit and asked to participate in the study. Eight patients (5%) did not meet the study criteria. O f the 143 eligible patients, 18 patients (13%) refused to participate and 1 patient withdrew during data collection. Two patients stated that the audiotaping process used to record the encounter was their reason for refusal to participate. The final sample included 124 individuals, an 87% response rate. One patient chose to turn off the recorder for a portion ( - 5 minutes) of the taped interaction. Individual patients were included in the study only once; each provider was recorded with 12 to 14 patients. The majority of patients were women (60%) and white (94%). The average age was 53.8 years. There were no significant differences between respondents and nonrespondents in age, sex, or race. Approximately 35% o f the respondents were di-

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vorced, and 53% had an annual income less than $7,000. More than half (65%) had completed high school. The great majority (91%) were being tbllowed tbr chronic conditions (cardiovascular and/or peripheral vascular, neuroendocrine, musculoskeletal, respiratory, gastrointestinal), reflecting the clientele of the hospital-based outpatient clinic. Few patients (2%) were being seen for health prevention or maintenance purposes. The number of clinic visits incurred by individuals during the previous year ranged from 4 to 27 (M 8.5; SD 4.9; mode 4.0). The majority of patients (65%) had been seen by a primary care provider at the clinic less than eight times during the past year. Approximately 85% had been seen by their primary provider at least three times, with a range of 3 to 18 visits (M 4.9; SD 2.7; mode 4.0).

Instruments Provider Communication Style Rating Scale. The Provider Communication Style Rating Scale (PCSRS) was developed for this study to be used with audiotaped provider-patient interactions analyzed by trained raters (Lawson, 1995). The scale contains indicators of informational and controlling interactions. The rating scale consists of 18 seven-point Likert-type items, 9 informational (e.g., the provider provides an opportunity for the patient to express his or her own thoughts and issues) and 9 controlling (e.g., the provider redirects the conversation away from the patient's agenda toward the provider's agenda), and measures a provider's predominant style of communication. The controlling items are recoded before summing the score for the scale; the range of scores is 18 to 126. A mean score for each taped visit is calculated. Total mean scores on the PCSRS can range from 1 to 7; higher scores reflect a more informational style. Initial content validity for the instrument was established through work with Deci, the creator of the self-determination theory, and the instrument was pilot tested using audiotapes and raters not included in the current study. A minimum interrater reliability of 70% agreement was set for analysis of the audiotapes. Interrater reliability was maintained above the established minimum during the pilot study (72% x 1 tape; 100% x 3 tapes); during training of raters for the current study (78 % × 1 tape; 89% x 1 tape; 100% x 2 tapes), and

throughout the study (83% × 1 tape; 89% × 1 tape; 94% X 1 tape; 100% X 4 tapes). The raters were non-healthcare professionals, unknown to the providers, and blinded to the provider's profession. Tapes were randomly assigned to the raters in an attempt to further diminish the possibility of systematic bias. During the study, interrater reliability was checked whenever the two raters completed rating a set of 10 audiotapes; a total of seven interrater reliability checks were performed. Health Care Climate Questionnaire. Patientperceived support for autonomy was considered to represent perceptions of the climate established by the provider. Patient-perceived autonomy support was measured by the Health Care Climate Questionnaire (HCCQ) developed by Williams et al. (1996). This instrument has 16 items in a sevenpoint Likert-type lbrmat (e.g., I am able to be open with the physician/nurse practitioner during our meetings, the physician/nurse practitioner handles people's emotions very well). The 16 items are summed, and scores can range from 16 to 112. Higher scores reflect patients' perception of the provider-patient relationship as supportive of their capacity to actively participate in decision-making regarding health care. The alpha coefficient in this study (0.93) indicated satisfactory internal consistency. Reliability and concurrent and discriminant validity have been previously supported (Deci & Ryan, 1985). Patient Satisfaction Questionnaire. Patient satisfaction in a healthcare context has been shown to be a multidimensional concept and has been linked to specific patient demographics, patient motivation, and styles of provider communication. In this study, patient satisfaction with the providerpatient relationship was measured by the Patient Satisfaction Questionnaire (SQ) developed by Bertakis, Roter, and Putnam (1991). The scale is composed of five subscales and three global items in a five-point Likert format; only three of the subscales (i.e., task directed skills/competence, attentiveness, emotional support) were used for this study because items in the partnership and interpersonal skills subscales are similar to several items in the HCCQ. A lower score indicates a higher level of satisfaction. In this study, a total score (range = 21 to 105) was used. The alpha coefficient in this study (0.94) indicated satisfactory internal consistency for the scale. Reliability

PROVIDER COMMUNICATION STYLES

and validity for the SQ have been previously supported (Bertakis et al.).

Procedures Eligible providers were given an overview o f the study before they were asked to participate. Participation involved completion of a consent form, a provider demographic questionnaire, and 12 to 14 audiotaped provider-patient interactions. Patients who met the study criteria were approached to participate in the study immediately before their scheduled appointment. Subjects were given a sheet containing information about the study, and it also was explained verbally by the researcher. Written consent was obtained to (1) allow the researcher to audiotape the actual office visit with the provider, (2) complete questionnaires, and (3) copy relevant information from the medical record. Audiotapes of provider-patient interactions were obtained using voice-activated recorders, which eliminated the need for the presence of the researcher. Chart review provided confirmation of patient demographic data, the patient problem list, record of visits, history of providers seen, and care plan for the recorded visit. R ESU LTS

Although responses on the total SQ varied (range = 21 to 88), patient satisfaction with the provider-patient relationship was generally high, evidenced by the low mean score (total scale, M = 32.80, SD = 11.80). Scores on the HCCQ also varied (range = 28 to 112), but again, perceived support for autonomy was high, reflected in the high mean score (M = 104.15, SD = 11.98). When scores on the PCSRS were converted to mean scores (M = 5.69, SD = 1.08, range = 2 to 7), it was clear that providers tended to use an informational style (mean score > 4.00). The great majority of interactions (N = 124), 91%, were higher than a mean of 4.00; in only 8% of the interactions did providers use a more controlling communication style (mean score < 4.00). In 1% o f the interactions, a mean score o f 4.00 was obtained, indicating no predominant style. Surprisingly, provider communication style was not significantly correlated with patient-perceived autonomy support (r .03, p .38) or patient satisfaction (r = .09, p = .16).

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Patient scores were aggregated lbr each provider, and a grand mean score was calculated lbr all tapes of each provider. Grand mean scores less than 4.00 were considered indicative of a controlling style, and those greater than 4.00 were indicative o f an informational style. Providers were overall more informational in their communication style (M 5.69, SD 1.08), and both NPs and PHYs used a predominate informational style (NR M 5.38, SD 0.46; PHY, M 6.08, SD 0.37). However, four of the providers (all NPs) had a range o f scores (2.78 to 6.78, 2.00 to 6.67, 2.38 to 7.00, 3.11 to 6.89) that indicated their style was more controlling when communicating with certain patients.

Providers w e r e o v e r a l l m o r e informational in their c o m m u n i c a t i o n style.

One-way analysis of variance showed that some significant differences in communication style (F 5.90, df 1/8, p .05) existed; PHYs used a slightly more informational style of communication overall. Because of the skewed distribution (skewness 1.26) of the scores, provider communication style (PCSRS) data also were examined with the more conservative Mann-Whitney U nonparametric test (p = .03). The results supported the initial findings. A second analysis of variance was performed to determine whether there were differences in communication style among individual providers and whether a particular provider might be responsible for the significant differences between provider groups. Communication style differed significantly ( F = 4.28, d f = 8/123, p < .0001) among individual providers. Scheff6 tests highlight the nature o f these differences (Table 1). Scheff6 tests represent the comparison of each provider's communication style (grand mean score on the PCSRS). Seventeen of 36 comparisons differed significantly. Thirty percent (3 of 10) of the comparisons between NPs were significant; 50% of the comparisons between PHYs (3 of 6) were significant. Eleven of 22 comparisons of NPs and PHYs (55%) were significant. One of the NPs (no. 2) rated lower on the PCSRS (less informational) than all

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Table 1. Results of Scheffe Tests of Differences Among Individual Provider Communication Styles: Nurse Practitioners (N = 5) and Physicians (N = 4) Provider

NP #1

NP #1 NP #2

#2 *

#3 NS ¢

NP #3 NP #4

PHY #4 NS

#5 NS

#1 f

#2 f

#3 f

#4 NS

¢

¢

¢

¢

¢

NS

NS NS

NS ¢

NS *

NS *

NS NS

f

f

NS

NS

NS NS

¢

NP #5

f

PHY#1 PHY#2 PHY#3

t

Abbreviation: NS, nonsignificant.

*p fp

< <

.08. .03.

the other providers. Another NP (no. 3) was similar to 7 of the remaining 8 providers in her communication style. One PHYs (no. 4) was rated lower on the PCSRS (less informational) than the other physicians; this physician's rating was similar to the ratings received by all the NPs. Individual items on the provider communication style rating scale also were examined by provider type. Mean scores for NPs on the nine informational items ranged from 4.19 to 5.90, and for PHYs, from 5.00 to 6.42; PHYs had a higher mean on all nine items. Thus, on all communication characteristics, PHYs were rated more informational. Both provider types were least informational and supportive in regard to encouraging patient participation and negotiation in making decisions relating to healthcare issues. Both provider types were willing to use words and phrases denoting support, attainment, or rewards based on competence. Both NPs and PHYs also tended to provide meaningful feedback through information that supported, confirmed, or promoted patient competence and facilitated provider and patient expression of personal information and comments. Mean scores for NPs on the nine controlling items ranged from 1.64 to 3.77, and for PHYs, from 1.27 to 3.00; PHYs had lower mean scores on all nine items and thus were rated less controlling. NPs and PHYs scored the highest mean on an item indicating their tendency to restrict opportunities for the patient to participate in the decision-making process and lowest on an item indicating the likelihood of their engaging in criticism rather than

praise for the patient or patient perlbrmance. PHYs' scores indicated that they were likely to limit acknowledgment, expression, or resolution o f potential conflict between themselves and the patient and redirect the conversation away from the patient's agenda toward the provider's agenda. NPs were more likely to promote predominance of provider talk, impeding or preventing patient exposition, and to use interviewing techniques that did not lbster patient participation. To assess whether differences between provider groups might be accounted for by differences in the patients cared for by the two groups, patients' age, sex, race, level o f perceived autonomy support, and satisfaction were examined by group. No significant differences in the patients cared for by the two provider groups were found. DISCUSSION

Unexpectedly, provider communication styles were not associated with patient satisfaction or patient-perceived autonomy support. These findings are in contrast to those of other investigators (Bertakis et al., 1991), who found that informational interactions between providers and patients facilitating patient control were correlated positively to patient outcomes. The differences in findings may be related to this study's' patient population, which was less racially diverse, younger, and had a lower annual income than those in the study of Bertakis et al. The lack of relationship also may reflect the small number of providers and restricted range of scores, reflecting high satisfaction on the SQ.

Unexpectedly, provider communication styles were not associated with patient satisfaction or patient-perceived autonomy support.

There was a pattern o f differences between NPs and PHYs that cut across multiple NPs and PHYs. Overall, providers were more informational in their communication styles; however, their style was more controlling when communicating with certain patients. Therefore, the question is what patient characteristics or behaviors (e.g., decreased

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adherence to medical regimen, decreased recall o f health information) might m a k e a p r o v i d e r adjust his or her style to one that is more controlling. A l t h o u g h no data were collected on this question, anecdotally, the raters identified several patient characteristics and behaviors that resulted in providers e n g a g i n g in more controlling c o m m u n i c a tion strategies. Patients w h o had " u n h e a l t h y " lifestyles or chronic diseases and chose to continue behaviors that providers identified as detrimental to their r e c o v e r y or m a i n t e n a n c e were m o r e likely to be told what was expected o f them, what changes in behaviors w e r e necessary, and w h e n they w e r e not p e r f o r m i n g as expected; the result was less i n v o l v e m e n t o f patients in negotiating a plan o f care. P H Y s overall were m o r e informational in their c o m m u n i c a t i o n style than NPs. This finding in part m a y reflect recent responses to the need to include interviewing and c o m m u n i c a t i o n courses in medical school curricula and continuing education and to evaluate the process and o u t c o m e s o f that education (Levinson & Roter, 1993). Historically, c o m m u n i c a t i o n skills h a v e been included and integrated into nursing curricula; however, evaluation o f the process and o u t c o m e s o f these skills has been relatively absent. These findings must be v i e w e d within the limitations o f the research. The sample was a small c o n v e n i e n c e sample o f providers from the same clinic setting. The providers worked in teams, interacted collaboratively on a daily basis, and had w o r k e d in the s a m e setting for at least 2 years. E v i d e n c e f r o m other studies suggests that "joint

practice" team m e m b e r s influence each other o v e r time (Wasserman & Inui, 1983). Providers thus could h a v e b e c o m e m o r e similar in their clinical styles, including their styles o f c o m m u n i c a t i n g with patients. Although di~Erences were evident in provider communication styles, more specific comparisons between NPs and PHYs were limited by the small number of providers, the absence of male NPs, and the inclusion of only one female PHY. Whether differences found were provider related, gender related, or related to time in practice cannot be sorted out in this study, but are possible alternative explanations. The core o f the provider-patient relationship is the interaction that occurs within the context o f the encounter. Examination o f the provider-patient interaction is one approach to uncovering the process and skills used by providers in an attempt to better understand h o w o u t c o m e s are affected. It is important to define precisely what NPs bring to the situation and what they do when they c o m m u n i c a t e with patients that might account for changes in health status and quality o f care. C o n t i n u e d e x a m ination o f c o m m u n i c a t i o n styles will have implications for NPs in practice and nurse educators responsible for teaching the skills necessary to provide patient-centered care.

The core of the provider-patient relationship is the interaction that occurs within the context of the encounter.

REFERENCES

Bertakis, K.D., Roter, D., & Putnam, S.M. (1991). The relationship of physician medical interview style to patient satisfaction. The Journal o/'Family Practice, 32, 175-181. Campbell, J.D., Mauksch, H.O., Neikirk, H.J., & Hosokawa, M.C. (1990). Collaborative practice and provider styles of delivering health care. Social Science & Medicine, 30, 1359-1365. Courtney. R., & Rice, C. (1997). Investigation of nurse practitioner-patient interactions: Using the nurse practitioner rating form. The Nurse Practitioneg 22 (2), 46 65. Deci, E.L. (1980). The psychology qfl se!f-determination. Lexington, MA: D.C. Heath & Company. Deci, E.L., & Ryan, R.M. (1985). h~trinsic motiwztion and self determination in human behavio~ New York: Plenum Press. Drury, M., Greenlield, S., Stilwell, B., & Hull, F.M. (1988). A nurse practitioner in general practice: Patient perceptions and

expectations. Journal of the Royal College of General Practitioners, 38, 503-505. Hall, J.A., Milburn, M.A., Roter, D.L., & Daltroy, L.H. (1998). Why are sicker patients less satisfied with their medical care'? Tests of two explanatory model. Health Psycholog); 17 (1), 70-75. Lawson, M.T. (1995). Provider communication styles in the context of established provider-patient relationships: Patient's perceived autonolny support and satisfaction with the relation ship. Dissertation Abstracts International, 56, 12B. (University Microfilms No. 9604536). Levinson, W., & Roter, D. (1993). The effects of two continuing medical education programs on communication skills of practicing prinlary care physicians. Journal of Internal Medicine, 8, 318-324. Roter, D.L., Stewart, M., Putnam, S.M., Lipkin, M., Stiles,

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W., & Inui, T.S. (1997). Communication patterns of primary care physicians. JAMA, 227, 350-356. Wasscrlnan, R.C., & lnui, T.S. (1983). Systemalic analysis of clinician-patient interactions: A critique of recent approaches with suggestions for future research. Medical Care, ll, 279293. Williams, G.C., & Deci, E.L. (1996). Internalization of bio-

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psychosocial values by medical students: A test of self-determination theory. Journal of Personality and Social Psycholog3; 70, 767 779. Williams, G.C., Grow, V.M., Freedman, Z.R., Ryan, R.M., & Deci, E.L. (1996). Motivational predictors of weight loss and wcight loss lnaintcnance. Journal of Personality and Social Psychology, 70, 115-126.