Identity construction in nurse practitioner-patient interactions

This dissertation explores interactions between Nurse Practitioners (NPs) and patients during both inpatient and outpatient visits. Through an analysis of interactional data coupled with ethnographic observations and interviews, I focus on the ways that both patients and providers construct particular identities, that is, how they inhabit the institutional role of patient or provider through particular linguistic moves and stylistic choices. A great deal of scholarly effort has been devoted to understanding language use in medical visits; however, these studies have focused almost exclusively on medical doctors (MDs) and have primarily taken a Conversation Analytic (CA) approach. This study departs from both of these traditions by examining interactions involving an understudied yet growing provider-type: Nurse Practitioners, and by employing an ethnographic discourse analytic methodology. Although they have not been a focus on linguistic study, Nurse Practitioners are recognized in the field of health communication as employing a ‘patient-centered’ approach, which seeks, among other things, to create positive, long-term relationships with patients. Additionally, NPs are recognized as providing a high quality of care measured in terms of patient satisfaction and health outcomes (i.e. improved health). However, what contributes to NPs’ positive evaluations has not been examined in depth, particularly in terms of language use in medical visits. In this dissertation, I address this gap in the literature by employing ethnographic discourse analysis that draws on multiple data sources. The analysis primarily focuses on audio-recordings of 48 medical visits with five different NPs: one working in an inpatient setting; four working in an outpatient setting. In addition to the audio recordings of medical visits, the study also includes interviews with providers and patients, focusing on ethnographic and bio data with the former and overall satisfaction with the latter. Drawing on both emic and etic categories of types of providers and patients, I argue that NPs, through their ability to balance both instrumental and interactional goals, are able to construct the identity of the ‘caring and competent’ provider. Using Agha’s (2007) theory of figures of personhood, I outline the ways in which NPs align with the ‘caring provider’ through linguistic moves of solidarity such as engaging in small talk, using inclusive first person plural pronouns and mitigating medical advice through the use of hedging and indirect speech. Employing these linguistic features allows the NPs to highlight and address the interpersonal goals of the medical visit, enabling them to create positive patient-provider relationships. Similarly, NPs balance the focus on the interpersonal with addressing the instrumental goals of the visit in their alignment with the ‘competent provider.’ This is accomplished through attending to their occupational and professional responsibilities including following the required medical checklist, recognizing their epistemic responsibility to patients, and creating alignments to their organizations and professional institutions. Additionally, NPs also highlight their own medical competency through the use of knowledge sharing and use of singular first person pronouns. Patients, in their enactment of the patient role, align with a number of different identities. Some align with the ‘deferent patient,’ likely a reflection of the older, provider-centered approach; however, this identity is never sanctioned by the NPs. Instead, NPs actively encourage patients to be more proactive in their own health and encourage this; those who do so, I argue, enact the ‘good patient.’ Other patient identities also seem to derive from the new patient-centered model of health care as well as the medical neoliberal ideology, which places patients in the role of ‘patient-consumer’ and requires them to take an active part in improving their health. Although not all patients are able to enact the medically compliant and ‘good patient’ identity, attempts that fall short of doing so are still viewed somewhat positively by the NPs, thereby aligning these patients with a number of other identities. Support for the NP identity of the ‘caring and competent’ provider, comes from interview data with both NPs and patients. NPs construct their own professional identity as teacher and information provider. Almost all NPs interviewed make it clear that they do not ‘push’ patients but simply focus on educating patients so that they can make the best decision for themselves. In doing this, they illustrate how avoidance of giving medical directives, among other things, allows them to create positive relationships with patients and, hopefully, encourage medical adherence. Patients’ responses to satisfaction questions in post-visit interviews also support this identity. Patients overwhelmingly indicate positive impressions of the NPs in the study and report on specific aspects such as showing concern for patients and being knowledgeable. This dissertation illustrates the ways in which employing an ethnographic discourse analytic framework allows for an analysis of identity construction in medical settings. The extent to which the identities that NPs align with are unique to NPs is a question that cannot be answered with this research alone since prior research focused on different goals and utilized different analytic and methodological frameworks. Future research should attempt more accurate and equitable comparisons of various provider types by exploring the ways in which linguistic choices aid in the construction of medical providers’ professional identities