WHAT ACTIONS CAN NOVICE NURSE PRACTITIONERS TAKE TO DEVELOP
AND MAINTAIN THERAPEUTIC RELATIONSHIPS WITH ADULT PATIENTS IN
PRIMARY CARE?
By
Tasenka Nicole Kushner
BScN, University of the Fraser Valley, 2006

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE IN NURSING; FAMILY NURSE PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
May 2017
© Tasenka Kushner, 2017

ii
Abstract
Therapeutic relationships between health care providers and patients can have wide
effects on patients’ health outcomes. There is a significant body of literature that has investigated
therapeutic relationships in nursing and medicine. However, there is a lack of literature
investigating therapeutic relationships between nurse practitioners and patients in primary care.
The purpose of this integrative literature review is to identify actions that novice nurse
practitioners can take to develop and maintain therapeutic relationships with adult patients in
primary care. Using an integrative literature review approach, actions related to competence and
knowledge, valuing and affirming exchanges, patient engagement and reciprocity, and
appreciating context were identified. Engaging in these actions may help novice nurse
practitioners develop and maintain therapeutic relationships with patients in primary care.
Focusing on the British Columbian practice environment, this review makes recommendations
related to professional identity, solidarity, role ambiguity, patient empanelment, complex
patients, and transitions in care.

iii
TABLE OF CONTENTS
Abstract

ii

Table of Contents

iii

List of Tables

v

List of Figures

vi

Acknowledgement

vii

Dedication

viii

Chapter One

Introduction

1

Chapter Two

Background and Context
Therapeutic Relationships in Primary Care and Patient Outcomes
Therapeutic Relationships Between Patients and Nurses,
Physicians, and Nurse Practitioners
Challenges for Novice Nurse Practitioners’ and the Effects on
Therapeutic Relationships
Summary

3
4

13
16

Chapter Three

Method
Search Strategy and Preliminary Search
Application of Inclusion and Exclusion Criteria
Analysis of Final Articles

18
18
21
24

Chapter Four

Findings
25
The Nurse Practitioner-Patient Therapeutic Encounter
25
Solidarity, Alignment, and Identity Construction in Nurse Practitioner
Patient Interactions
27
The Empathetic Partnership Framework
32
Essential Meanings of Nurse Practitioners’ Lived Experiences Interacting
with Patients
34
Nurse Practitioner-Patient Interaction as Resource Exchange
36
Patients’ Assessments of Consulting a Nurse Practitioner
38
Summary
40

Chapter Five

Discussion
Key Findings
Implications and Recommendations for Clinical Practice
Professional Identity
Recommendations
Solidarity

7

42
42
48
48
49
50

iv
Recommendations
Role Ambiguity
Recommendations
Patient Empanelment
Recommendations
Complex Patients
Recommendations
Care Transitions
Recommendations
Summary
Recommendations for Research
Limitations
Summary and Conclusion
References

50
51
51
53
53
54
54
55
56
56
57
58
59
61

Appendix A

Literature Review Matrix

66

Appendix B

Themes and Subthemes

73

Appendix C

Factors, Elements, Resources, and Meanings by Article

74

Appendix D

Summary of Implications and Recommendations

76

v
List of Tables
Table 1: Search Terms and Combinations with Results

20

Table 2: Inclusion and Exclusion Criteria

22

Table 3: Summary of Actions by Theme

44

vi
List of Figures
Figure 1: Literature Search Strategy

23

vii
Acknowledgement
It is not the brains that matter most, but that which guides them–the character, the heart,
generous qualities, progressive ideas (Fyodor Dostoyevski, The Insulted and Injured, 1861)

•

•

•

•

•

•

•
•

I offer my sincerest gratitude to:
My advisory committee members Dr. Martha MacLeod, PhD, RN and Erin Wilson,
PhD, NP(F), for their unwavering confidence in me, and for their extraordinary patience,
insightful guidance, and ample encouragement in helping me to complete this project.
All of the UNBC faculty, including my course instructors, clinical faculty, oral
examination chair and external examiner, and administrative and technical support staff,
for all their wonderful lessons, feedback, and support.
My clinical preceptors Dr. Hugh Fletcher, Eunice Finch, NP(F), Bobbie Adkins, RM,
Celia Evanson, NP(F), and Nikita Ivanov, NP(F) for encouraging, probing, pushing, and
just overall providing me with exceptional learning environments. I would also like to
acknowledge the support of Karen Remo, NP(F), Bonnie Leung, NP(F), Dr. Kim Chi,
and Dr. Sunil Parimi, whom I also worked with closely at my BCCA placement.
Sherri McTavish, Tannis Chequist, Leah Smith, Barbara Smith, and Rob Gathercole and
Megan Ireland, for providing me with welcoming, comfortable homes in which to stay
during my practicums away from home.
My sister Troye Hanssens and brother Adam Middleton for their continual hospitality
and generosity in housing me in their wonderful home in Prince George each time I was
on campus. And to their dogs, Pepper Eleanor and Kevin the Grey, for providing me with
stress relief while I was on campus.
My family, especially my parents Bob and Ann, sister Nashira, and grandmother Anna–
who have believed in me for as long as I can remember–for their steadfast love, caring
and encouragement in many forms, and for their patience and understanding during my
many absences from home for practicums.
My friends and colleagues, for their motivation, encouragement, and championing.
My nurse practitioner student colleagues, for their understanding, sharing, inspiration,
and friendship.

viii
Dedication
To my grandmother, Anna Kushner, and late grandfather, Carl Kushner, for their strength, spirit,
humour and authenticity, and for inspiring my nursing career.
What we know cures; who we are heals (Kuhl, 2013, p. 1).

1
Chapter One
Introduction
In British Columbia, about 34% of nurse practitioners are employed in community health
centres, home care agencies, nursing stations, and public health units (Canadian Institute for
Health Information [CIHI], 2015), where primary care is provided to patients with a variety of
conditions and concerns. In primary care, patients most value the communication they have with
their primary care provider and care that is consistent with their preferences and values (Laberge
et al., 2014). These patient values are not directly related to the technical aspects of medical care,
like disease management, but rather reflect the importance of therapeutic relationships. There is
a significant body of literature that has investigated therapeutic relationships in nursing and
medicine. However, there is little research that directly investigates therapeutic relationships
between nurse practitioners and patients in primary care, or how the challenges experienced by
novice nurse practitioners affect their ability to develop and maintain therapeutic relationships
with patients in primary care. Researchers have observed that therapeutic relationships between
health care providers and patients can have positive effects on patients’ health outcomes
(Greenfield, Kaplan, Ware, Yano, & Frank, 1988; Griffin et al., 2004; Hojat et al., 2011; House,
Landis, & Umberson, 1988; Kaplan, Greenfield, & Ware, 1989; Kelley, Kraft-Todd, Kossowsky,
& Riess, 2014; Krumholz et al., 1998; Mohammadi, Abedi, Jalali, Gofranipour, & Kazemnejad,
2006; Mumford, Schlesinger, & Glass, 1982; Peplau, 1997; Street & Voight, 1997; Ward et al.,
2003). Without developing and maintaining therapeutic relationships, novice nurse practitioners
may not be able to fully achieve a wide variety of positive health outcomes with their patients.
Nurse practitioners are a relatively new type of primary care provider in British
Columbia, with nurse practitioners first becoming regulated in the province in 2005 (College of
Registered Nurses of British Columbia [CRNBC], 2017). This literature review focuses on the

2
practice environment of novice nurse practitioners in primary care in British Columbia and the
specific considerations related to the current state of integrating nurse practitioners in this
location. In adapting to their new role in the context of primary care in British Columbia, novice
nurse practitioners in particular may require targeted support to develop and maintain therapeutic
relationships. The purpose of this integrative literature review is to identify actions that novice
nurse practitioners can take to develop and maintain therapeutic relationships with adult patients
in primary care.
The second Chapter explores the context of primary care; the influence of therapeutic
relationships on patient outcomes; the history and present context of therapeutic relationships
between patients and nurses, physicians, and nurse practitioners; and challenges for novice nurse
practitioners that may impact how they are able to develop and maintain therapeutic
relationships in primary care. The third Chapter outlines the approach to this project, describing
the literature review method. The fourth Chapter describes the findings from the critical analysis
and evidence synthesis of the literature. Finally, the fifth Chapter reviews the key findings and
implications for practice, and provides recommendations for clinical practice and research.

3
Chapter Two
Background and Context
There are many definitions of therapeutic relationships, depending on discipline.
Nursing, medicine, physiotherapy, psychology, sociology, philosophy, and other fields describe
therapeutic relational processes, provider competencies, and relational outcomes similarly.
Regardless of professional group, patients expect a therapeutic relationship or rapport to develop
between them and their health care provider (Kitson, Marshall, Bassett, & Zeitz, 2013). A
therapeutic relationship can be simply defined as the interpersonal connection that occurs as the
result of the interaction between a health care provider and a patient (College of Family
Physicians of Canada, 2016). Since education, experience, focus, and context differ across
professions (e.g., nursing and medicine), there are likely to be variations in how members of
different professions approach or conduct the interpersonal process between themselves and their
patients.
Nurse practitioners are a newer type of primary care provider in British Columbia, with
nursing and advanced practice nursing education and experience. Accordingly, nurse
practitioners approach therapeutic relationships with patients from two different health care
perspectives. Thus, it is important to explore the theoretical and historical bases of therapeutic
relationships for nurses, physicians, and nurse practitioners in order to determine how
developing and maintaining therapeutic relationships in primary care may be different for novice
nurse practitioners. In addition, potential practice challenges associated with the integration of
nurse practitioners may impact how they interact with patients. Hence, it is important to explore
practice challenges of novice nurse practitioners. Furthermore, the context of professional
specialties (e.g. oncology and primary care) can impact therapeutic relationships due to
differences in the purpose of the visit and temporal aspects of the relationship (Squier, 1990).

4
Thus, it is important to explore the context of primary care. This chapter is divided into three
sections to discuss the context of primary care and the influence of therapeutic relationships on
patient outcomes; the history and present context of therapeutic relationships between patients
and nurses, physicians, and nurse practitioners; and the challenges for novice nurse practitioners
that may impact how they are able to develop and maintain therapeutic relationships in primary
care. This chapter concludes with a summary.
It is important to first acknowledge that patient characteristics (age, gender, ethnicity,
socio-economic, culture) and personal preferences can influence how patients interact with
providers (Greenhalgh & Heath, 2010). Physical setting and environmental context can also
influence how patients and health care providers interact (Bentley, Stirling, Robinson, &
Minstrell, 2016). For example, health care providers may work in a clinic room where their desk
can only be positioned facing the wall, forcing them to position themselves with their back to
their patient during at least part of the interaction. Health care providers generally cannot change
patient characteristics and preferences, and may not be able to change the physical environment.
Instead, providers may aim to interact with patients in a way that is respectful and consistent
with the patient’s values (Wiechula et al., 2015). Novice nurse practitioners may be able to take
actions to develop and maintain therapeutic relationships with patients in primary care that may
be used with any patient and/or context.
Therapeutic Relationships in Primary Care and Patient Outcomes
The interactions and relationships between health care providers and patients in acute
care, specialty medical care, and surgery are typically time-limited. Thus, the understanding of
patient preferences and values of providers within those settings is limited to the time the patient
is actually in those settings. In addition, the relationship between health care providers and
patients in tertiary care may end when a certain goal is met. For example, an endocrinologist

5
may refer care back to the primary care provider after a patient with diabetes has been stabilized
on a new medication regimen. Primary care providers care for patients in a comprehensive way,
without intentions to terminate the relationship after a certain time period or after a certain target
has been achieved. Specific aspects of care may be referred to different providers or services, but
primary care providers continue to provide care for their patients, with repeated contact over
time (College of Family Physicians of Canada, 2016). Thus, relationships between providers and
patients in primary care are longitudinal. As new primary care providers, novice nurse
practitioners may not have practiced in a setting where they had the opportunity to have
longitudinal relationships with their patients. Consequently, novice nurse practitioners may
benefit from more information regarding what actions they can take to develop and maintain
therapeutic relationships with patients in primary care over longer periods of time.
Many events occur over time that impact both providers and patients and the relationship
between them. Squier (1990) argues that the longitudinal relationship between primary care
providers and patients can make a significant difference in patients’ ongoing quality of life and
ability to cope with chronic and/or recurrent illness. Continuity of primary care is associated
with better health, improved provider-patient communication, decreased emergency department
visits, and greater uptake of preventive and health promotion strategies (Burge et al., 2011;
Laberge et al., 2014). Difficult times and events that occur throughout patients’ lives highlight
the importance for providers to actively and thoughtfully take action to develop and maintain the
therapeutic relationship between themselves and their patients in primary care.
In a pan-Canadian report describing patient and physician perspectives on the quality of
and satisfaction with primary care, patients’ most highly rated values in primary care were
related to communication, continuity, coordination, and providing care that is consistent with
their preferences (Laberge et al., 2014). Values that were important to patients include being

6
known to their provider, being treated as a person and not just a medical problem, being listened
to attentively, being understood, being involved in decision-making about treatments; and having
a provider who is knowledgeable about their medical history, has their medical records at hand,
and knows when to refer to a specialist (Laberge et al., 2014). Having continuity with one most
responsible provider was not rated as highly (Laberge et al., 2014), suggesting that patients are
open to other providers, as long as these providers are knowledgeable about them personally. As
new primary care providers, novice nurse practitioners may benefit from connecting these values
to actions they can take to develop and maintain therapeutic relationships with patients in
primary care.
Discussing relationship quality is largely subjective, as is examining professional virtues
such as loyalty, honesty, and integrity, or mutual qualities of the therapeutic relationship like
respect, positive regard, and trust (Greenhalgh & Heath, 2010). Even though these qualities and
virtues are not easily measurable, their absence is very obvious, especially to patients who are ill
or vulnerable (Greenhalgh & Heath, 2010). In psychotherapy, Lambert (1992) estimated that the
nature of the therapist-patient relationship accounts for approximately 45% of the effectiveness
of therapy. The therapeutic relationship “may be the primary intervention to promote awareness
and growth and/or to work through difficulties… [or] may be more in the background, serving as
the intervention through which comfort, support, and provision of care are facilitated”
(Registered Nurses Association of Ontario, 2002, p. 11). For example, a health care provider
discussing prognosis with a patient recently diagnosed with terminal cancer may rely more
heavily on the therapeutic relationship compared to a health care provider taking a history from
an otherwise healthy patient who presents with symptoms of a respiratory tract infection.
Nonetheless, the therapeutic relationship underlies every interaction between provider and
patient.

7
Even though the influence of therapeutic relationships on health outcomes is difficult to
measure, Kelley et al. (2014) found that that the provider-patient relationship has a small but
statistically significant (p=.02) effect on health care outcomes such as general quality of life,
pain relief, depression/anxiety and other psychosocial outcomes, functioning, weight loss,
reconsultation rate, asthma quality of life, blood pressure, and smoking quit rate. Therapeutic
relationships have been found to confirm self-worth, provide a connection to others, and support
self-esteem (Peplau, 1997). Therapeutic relationships have also demonstrated measurable
improvements in many other health parameters (Griffin et al., 2004; Kelley et al., 2014), such as
improved diabetic management (Hojat et al., 2011), improved recovery from surgery and
myocardial infarctions (Mumford et al., 1982), decreased morbidity (Krumholz et al., 1998;
Ward et al., 2003), decreased mortality (House et al., 1988), improved quality of life in breast
cancer patients (Street & Voight, 1997), increased treatment adherence (Mohammad et al.,
2006), improved general health status (Kaplan et al., 1989) and generally improved clinical
outcomes (Greenfield et al., 1988). Overall, the above research findings demonstrate the diffuse
effects that therapeutic relationships can have on patients’ health. In addition, these health
outcomes emphasize the importance of developing and maintaining therapeutic relationships
with patients in primary care.
Therapeutic Relationships Between Patients and Nurses, Physicians, and Nurse
Practitioners
There are historical differences in the focus of nurse-patient relationships and physicianpatient relationships. There has been significant research in nursing about nurse-patient
relationships, which have been described as therapeutic relationships, and alternately as caring
relationships. As it is beyond the scope of this paper to describe each theory, the work of one
prominent nursing leader and pioneer will be featured here. Peplau, a psychiatric nurse, was the

8
first nursing theorist to identify the nurse-patient relationship as being central to all nursing care
(Peden, Staal, Rittman, & Gullett, 2015). Along with other nurse leaders that followed, Peplau
helped to shift the pre-20th century focus of nursing from performance of tasks to engagement in
therapeutic relationships designed to facilitate patients’ health and healing (Peden et al., 2015).
Peplau (1992) believed that the work of nursing is to engage the patient in therapeutic
relationships that move them toward greater health, and to do this nurses have to engage patients
rather than allowing patients to be passive recipients of nurse-directed care. In other words,
Peplau believed that therapeutic relationships should be patient-centered. Peplau described the
nurse-patient relationship as consisting of two or more people (nurse and patient/patient’s
family), professional expertise, and patient need. According to Peplau, every interaction with a
patient has the potential to be therapeutic, with the goal of the nurse-patient relationship to help
patients develop intellectual and interpersonal skills required for improved health and/or
wellness through the use of active listening skills and verbal and non-verbal communication
strategies.
The seminal work of Peplau is reflected in the College of Registered Nurses of British
Columbia’s position on therapeutic relationships. The College of Registered Nurses of British
Columbia (2013) states that nurse-patient relationships are the foundation of nursing practice and
describes these relationships as therapeutic; focused on patients’ needs; based on trust, respect
and professional intimacy; protective of patients’ dignity, autonomy, and privacy; and are
distinguished from non-professional relationships by professional boundaries and a focus on
therapeutic aspects. This description reflects many of the nursing values and ethical
responsibilities contained within the Canadian Nurses Association (CNA)’s Code of Ethics for
Registered Nurses, which include providing safe, compassionate, competent and ethical care;
promoting health and well-being; promoting and respecting informed decision-making;

9
preserving dignity; maintaining privacy and confidentiality; promoting justice; and being
accountable (CNA, 2008).
In contrast to the nursing profession, the medical profession has historically focused
more on disease management than relationships with patients (Donabedian, 1966). The
traditional biomedical agenda refers to a model for medicine that views people as biologic
systems, with disease occurring independent from social behaviour (Johnson, 1993). In this
model, relationships between physicians and patients are more restricted to the biomedical
agenda and aimed at achieving performance targets (Greenhalgh & Heath, 2010). Conversely,
one prominent physician, William Osler (1892), endorsed the importance of the physicianpatient relationship. However, evidence-based medicine was also beginning to change medical
practice around the same time (Silverman, 2012). It may have been that the demand for
evidence-based medicine overshadowed the attention to physician-patient relationships as
medical evidence rapidly increased. In keeping with the biomedical agenda, Donabedian (1966)
presented a framework for evaluating the effectiveness of medical care at the level of the
physician-patient interaction. Donabedian proposed that there are three categories from which to
measure quality of medical care: structure, processes, and outcomes. Using Donebedian’s
framework in primary care, the structure and process of primary care was arranged to attempt to
produce performance-related outcomes.
Inadvertently, the focus on performance-related outcomes diminished the importance of
the therapeutic relationship in achieving those health outcomes; family physicians may not have
focused on knowing patients, their concerns and priorities, their family and work life, or why
these things are important to health (Greenhalgh & Heath, 2010). Hence, developing and
maintaining therapeutic relationships may have been hindered. Fortunately, the work of
Levestein, McCracken, McWhinney, Stewart, and Brown (1986) began to bring more attention

10
back to the importance of physician-patient relationships in primary care. However, the
traditional disease-focused model of medicine persists and this approach continues to be evident
in practice today (Miller, Crabtree, Nutting, Stange & Jaén, 2010; Robinson, Tate, & Heritage,
2016; Sheridan et al., 2012). A disease-focused approach may be the result of increasing
pressures on the health care system from the current shortage (CIHI, 2016) and/or ineffective use
of family physicians (Berry et al., 2017). Nonetheless, the lens of medical care is historically
different from nursing. Thus, nurse practitioners, with their education and experience grounded
in nursing, may have a different perspective than physicians regarding therapeutic relationships
with patients.
Because the practice of nurse practitioners is grounded in nursing values and expanded
from the knowledge and theories of professional nursing practice (CNA, 2010), nurse
practitioners readily recognize the centrality of therapeutic relationships to their professional
practice with patients. Nurse practitioners bring the qualities and skills from their nursing
background (as well as their experiences using these skills as registered nurses) to their advanced
practice roles. Furthermore, the addition of advanced education at the Masters or Doctoral level,
including advanced practice nursing education (such as diagnosing, treating, and managing
diseases and illnesses, prescribing medications, ordering and interpreting laboratory and
diagnostic tests, and initiating referrals to specialists), means that nurse practitioner practice
encompasses medical competencies traditionally delivered by physicians, but from a nursing
epistemology (Prodan-Bhalla & Scott, 2016). The competencies for nurse practitioners in British
Columbia describe the knowledge, skills, attitudes and judgments required for nurse practitioners
(CRNBC, 2010), and provide some indication of the expectations for nurse practitioner-patient
interactions. The competencies that seem to be the most relevant to nurse practitioner-patient

11
interactions include those regarding the incorporation of knowledge into assessment, diagnosis,
therapeutic management, and evaluation of outcomes; the provision of information, support, and
education to patients; the use of advanced knowledge in communication, negotiation, coalition
building, change management, and conflict resolution; the creation of environments conducive to
communication, learning, and patient participation; the consideration of personal patient
information/attributes/perspectives/values/goals and evidence-informed practice when exploring
therapeutic options and negotiating plans of care with patients; and the provision of culturally
safe care (CRNBC, 2010, pp. 9-15).
Within the transition from registered nurse to nurse practitioner, there is an
accompanying shift in how nurse practitioners develop and maintain their therapeutic
relationships with patients, as the additional education and change in practice
environment/context allows novice nurse practitioners to interact with patients in ways that they
did not as registered nurses. Nurse practitioners have the opportunity to develop and maintain
therapeutic relationships with patients in the context of directly managing patients’ health
conditions through ordering investigations, medications and treatments, and making shared
management decisions. Advanced practice nursing education provides nurse practitioners’ with a
systematic approach to medical problems and new knowledge regarding diagnosing and
managing diseases and conditions, whereas entry-level nursing education and experience
working with patients as registered nurses guides nurse practitioners in how they approach
therapeutic relationships with patients. Thus, novice nurse practitioners must take their
knowledge of therapeutic relationships from their registered nursing background and apply this
knowledge to their new role as nurse practitioners in the context of primary care and new
practice challenges.

12
Despite the lack of literature that offers advice on developing and maintaining therapeutic
relationships between nurse practitioners and patients, there is literature that indirectly addresses
therapeutic relationships through evaluations of nurse practitioners’ practice, including patients’
evaluations of nurse practitioners’ care and nurse practitioners’ communication practices. Nurse
practitioners receive high levels of patient approval. Evaluations of nurse practitioners
demonstrate that patients believe nurse practitioners provide comprehensive care, attentiveness
to their needs, and a feeling of caring (Sangster-Gormley & Canitz, 2015). Charlton et al. (2008)
reviewed nurse practitioner-patient communication in primary care, and found that nurse
practitioner communication with patients reflects both the traditional biomedical/providercentered model and the patient-centered model. Charlton et al. argue that patient-centered
communication results in more positive patient outcomes. Given that nursing historically
adopted patient-centered communication (Peplau, 1992), the biomedical/provider-centered
communication that was identified by Charlton et al. indicates that there may be other factors
interfering with how nurse practitioners communicate with patients. Thus, examining nurse
practitioner-patient interactions in more depth, and examining factors that may interfere with
nurse practitioner-patient communication, may help determine actions that can be taken to
develop and maintain therapeutic relationships.
Although therapeutic attitudes, communication, and other factors are identified as
important to therapeutic relationships (Greenhalgh & Heath, 2010), it is also important to
consider the social context and power relationships within which these therapeutic attitudes,
communication, and factors take on particular, contextual meanings. In contrast to physician
studies, Grainger (2004) found that nurses use humour to balance power in relationships with
patients in geriatric wards and gain a sense of unity, or solidarity, between them. In addition,
Defibaugh (2014) discovered that nurse practitioners create solidarity with patients in ways that

13
have not been seen in previous studies of medical visits involving physicians. The findings from
Grainger (2004) and Defibaugh (2014) imply that nurse practitioners negotiate power in a way
that is linked to the patient-centered nursing perspective. In contrast, Li, Koehn, Desroches,
Yum, and Deagle (2007) found that physicians use power to gain more control over the topics
and course of the medical visit. Furthermore, as a display of power, questions can be used to
control the direction of conversation and determine when the patient may speak (AinsworthVaughn, 1998; Byrne and Long, 1976; Heritage and Clayman, 2010). Patients may also act
passively and display more silent behaviours with providers, perhaps as a way to show reverence
to their providers’ authority (Ainsworth-Vaughn, 1998; Heath, 1992; Stivers, 2007). Thus, the
ways in which providers consciously or unconsciously use power affect how they interact with
patients and how the therapeutic relationship is developed and maintained. Exploring how nurse
practitioners balance power during interactions with patients may reveal insights into the actions
that novice nurse practitioners can take to develop and maintain therapeutic relationships.
Challenges for Novice Nurse Practitioners’ and the Effects on Therapeutic Relationships
The transition from registered nurse to nurse practitioner, especially in the first year after
graduation, has been described as a stressful and turbulent time, regardless of practice setting
(Faraz, 2016). In her integrative review on novice nurse practitioner transition into primary care,
Faraz found the most common intrinsic obstacles faced by novice nurse practitioners were
perceptions of low competence and poor self-confidence in their new roles. In their study of
novice nurse practitioners’ transition into primary care, Brown and Olshansky (1997) found that
poor self-confidence greatly affects nurse practitioners initial transition into their roles as
primary care providers. Defibaugh (2015) affirms that the setting of medical care on its own
lends itself to defining general roles for participants (i.e., ‘patient’ and ‘provider’), and more
specific roles (e.g., ‘good patient’ and ‘competent provider’). Defibaugh (2015) asserts that these

14
roles aid in the construction of identities for both patients and nurse practitioners, and that these
identities shape interactional patterns between patients and nurse practitioners. Consequently, the
ways in which patients and nurse practitioners view themselves affect how they interact together.
While nurse practitioners have little control over how patients construct their identities as
patients, nurse practitioners may be able to control how they perceive themselves as nurse
practitioners and modify (to some extent) how patients perceive them. If some novice nurse
practitioners have poor self-identity, there may be repercussions for therapeutic relationships.
Exploring how nurse practitioners construct their identity may reveal actions that novice nurse
practitioners can take to improve their self-identity, thus improving their interactions with
patients, and helping to develop and maintain therapeutic relationships.
There are several other challenges identified from research about the registered nurse to
nurse practitioner transition that may affect the way that novice nurse practitioners develop and
maintain therapeutic relationships with patients. Although both physicians and nurse
practitioners work in primary care settings in British Columbia, there are differences between the
practice environment of nurse practitioners and that of physicians. The practice challenges of
nurse practitioners include role ambiguity; quality of professional and interpersonal
relationships; and extrinsic obstacles, including patient empanelment and lack of
privileging/credentialing.
Faraz (2016) found that role ambiguity is the most common issue in the nurse practitioner
transition to primary care. In their evaluation of the integration of nurse practitioners into the
British Columbia health care system, Sangster-Gormley and Canitz (2015) also identified that
managers, physicians, and other staff lack knowledge or understanding about the nurse
practitioner role. Prodan-Bhalla and Scott (2016) assert that the current funding models for nurse

15
practitioners also create barriers to role clarity for patients and professionals alike, and this
negatively impacts relationships with nurse practitioners.
The problem of role clarity may be more exaggerated in communities or settings where
nurse practitioners are being newly introduced. Lack of role clarity can create several challenges
with integrating nurse practitioners into practice teams, including unfair expectations, confusion
about nurse practitioners’ contributions, and tension in the relationships between nurse
practitioners and other professional groups and/or staff (Faraz, 2016; Sangster-Gormley &
Canitz, 2015). Lack of understanding about the nurse practitioner role can be a problem in
relationships between nurse practitioners and their colleagues (Sangster-Gormley & Canitz,
2015).
Lack of role clarity can also be passed on to patients. When patients are seen in
collaborative practice settings where patient rosters are shared, other practitioners may provide
patients with inadvertently false information about the role of the nurse practitioner. Thus, the
actions that novice nurse practitioners take in regards to improving role clarity may have
implications for their therapeutic relationships with patients.
Sullivan-Bentz et al. (2010) found that one third of nurse practitioner graduates from the
Ontario Primary Health Care Nurse Practitioner program reported interpersonal conflict or lack
of role acceptance in their practice environments. Lack of support from managers, physicians
and other colleagues or health care providers impacts nurse practitioners’ interprofessional
relationships. Lack of support may be demonstrated by a reluctance or refusal to provide
professional supports such as formal mentoring for novice nurse practitioners, consultative or
collaborative support from colleagues, or exclusion from practice meetings or other meetings. In
order to best care for their patients, nurse practitioners (especially novice nurse practitioners)
need support from management, colleagues, and other health care providers. Without these

16
supports, patient care may be impacted, and therapeutic relationships between nurse practitioners
and patients may be affected. Thus, the actions that novice nurse practitioners take in regards to
obtaining support and fostering interprofessional relationships may have implications for their
therapeutic relationships with patients.
The majority of nurse practitioners in British Columbia are employed by health
authorities (CIHI, 2015), so many nurse practitioners do not have the freedom to empanel their
own patients. Patient empanelment allows patients to register with a provider or family practice
team (The College of Family Physicians of Canada, 2012). Nurse practitioners in British
Columbia are often recruited by health authorities to improve access to care for certain panels of
patients, such as patients with chronic conditions and complexity (Sangster-Gormley & Canitz,
2015). Thus, nurse practitioners are often assigned to a particular patient panel, without any
patient or nurse practitioner input. There may be implications for therapeutic relationships when
these relationships are created without nurse practitioner and/or patient input.
In addition, the lack of privileging and credentialing for many nurse practitioners means
that nurse practitioners cannot follow patients across settings as other primary care providers
may choose to (Sangster-Gormley & Canitz, 2015). Hospital admitting privileges continue to be
an issue for many nurse practitioners. Despite nurse practitioners’ otherwise favorable
evaluations from patients, patients reported that they did not like that their nurse practitioners did
not have hospital admitting privileges (Sangster-Gormley & Canitz, 2015). Thus, the lack of
privileging has implications for therapeutic relationships between nurse practitioners and
patients.
Summary
It is clear that therapeutic relationships are important for patients and providers alike.
Nurse practitioners retain the values, theories, and knowledge of therapeutic relationships that

17
were established during their nursing education and experience practicing as registered nurses,
and combine this knowledge and these values with their advanced practice education to their
new roles as primary care providers. Thus, while novice nurse practitioners are new to their role
and new to the setting of primary care, engaging in therapeutic relationships is not new. Yet,
because of this new role and care setting, the approach to therapeutic relationships is necessarily
different. However, there is a lack of literature that directly examines how nurse practitioners
develop and maintain therapeutic relationships with their patients. Adapting to the new role and
context of primary care, novice nurse practitioners may require further direction or education
about engaging in therapeutic relationships with patients in primary care. Based on differences in
education, experience, focus, and practice challenges, the actions that physicians may take to
develop and maintain therapeutic relationships when they are new in their role may be different
than the actions novice nurse practitioners may take. Moving forward, the next chapter outlines
the methods used for the literature review in order to answer the question of what actions novice
nurse practitioners can take to develop and maintain therapeutic relationships with adult patients
in primary care.

18
Chapter Three
Method
Using criteria from Whittemore and Knafl (2005), an integrative literature review was
conducted, guided by the following question: What actions can novice nurse practitioners take to
develop and maintain therapeutic relationships with adult patients in primary care? The literature
search process occurred in the following three stages: (1) search strategy and preliminary search,
(2) application of inclusion and exclusion criteria, and (3) analysis of final articles. The searches
were last rerun on May 5, 2017, in order to determine whether additional articles might be
added.
Search Strategy and Preliminary Search
The preliminary literature search used the following databases, which were accessed
through the University of Northern British Columbia’s library: Cochrane Database of Systematic
Reviews (CDSR), CINAHL with Full Text, MEDLINE, PsycINFO, and Social Sciences with
Full Text. These databases were selected because they represented sources of a wide selection of
original research articles and systematic reviews from the areas of medicine, nursing, and social
sciences, which were all relevant to the topic of therapeutic relationships. Medical databases and
journals were included to widen the scope of the results, so as not to miss relevant literature on
nurse practitioners that may appear in non-nursing journals. Because of the large body of
literature available about provider-patient relations, designing the search strategy was a
challenge. In order to ensure a thorough search of the literature, search terms were developed by
breaking down the key components of the research question. These individual search terms were
then combined in various ways in keyword searches, using appropriate truncation, and
formulated into MeSH terms when available. MeSH terms were exploded where possible. This
search strategy improved the relevance of search results and decreased the time spent sorting

19
through extraneous results. The search terms and combinations with results can be found in
Table 1. The types of journals found in the results included those dedicated to primary care,
applied communication, general medicine, and nursing.
The following websites were also searched for relevant guidelines pertaining to
therapeutic relationships: Academic Consortium for Integrative Medicine and Health (United
States), Agency for Healthcare Research and Quality (United States), Canadian Foundation for
Healthcare Improvement, Canadian Institute for Health Information, University of British
Columbia Research Circle, National Institute for Health Research (United Kingdom), and
National Institutes of Heath (United States). No relevant guidelines were found for inclusion.

20
Table 1
Search Terms and Combinations with Results
Databases
CDSR
(Ovid)

CINAHL
with Full
Text
(EBSCO
host)

MEDLINE
(Ovid)

PsycINFO
(EBSCO
host)

Social
Sciences
with Full
Text
(EBSCO
host)

Search Terms and Results
1. SH “Nurse practitioners+”= 0
2. (SH "Family Practice") OR (SH
"Physicians, Family")= 0
3. (SH "Professional-Patient Relations") OR
(SH "Physician-Patient Relations") OR (SH
"Nurse-Patient Relations") = 0
4. KW “Therapeutic relationship”= 57
5. KW “Primary care” = 1077
1. MH “Nurse practitioners+” = 16064
2. (MH "Family Practice") OR (MH
"Physicians, Family") = 20288
3. MH "Professional-Patient Relations") OR
(MH "Physician-Patient Relations") OR (MH
"Nurse-Patient Relations") = 58930
4. KW “Therapeutic relationship”= 958
5. KW “Primary care”= 34501
1. SH “Nurse practitioners+”= 16643
2. (SH "Family Practice") OR (SH
"Physicians, Family")= 77022
3. (SH "Professional-Patient Relations") OR
(SH "Physician-Patient Relations") OR (SH
"Nurse-Patient Relations") = 133970
4. KW “Therapeutic relationship”= 1771
5. KW “Primary care”= 82870
1. MH “Nurse practitioners+”= 0
2. (MH "Family Practice") OR (MH
"Physicians, Family") = 0
3. MH "Professional-Patient Relations") OR
(MH "Physician-Patient Relations") OR (MH
"Nurse-Patient Relations") = 0
4. KW “Therapeutic relationship”= 6904
5. KW “Primary care”= 33430
1. MH “Nurse practitioners+” = 94
2. (MH "Family Practice") OR (MH
"Physicians, Family") = 21
3. MH "Professional-Patient Relations") OR
(MH "Physician-Patient Relations") OR (MH
"Nurse-Patient Relations") = 4
4. KW “Therapeutic relationship”= 1870
5. KW “Primary care”= 4043

Combinations and Results
Combinations:
1 + (3 OR 4) = 0
1 + 2 + 3= 0
1 + 2 + 4= 0
1 + 3 + 5= 0

Combinations:
1 + (3 OR 4) = 587
1 + 2 + 3= 35
1 + 2 + 4= 0
1 + 3 + 5= 99
(Total 572 non-duplicate)
Combinations:
1 + (3 OR 4) = 656
1 + 2 + 3= 57
1 + 2 + 4= 0
1 + 3 + 5= 118
(Total 644 non-duplicate)
Combinations:
1 + (3 OR 4) = 0
1 + 2 + 3= 0
1 + 2 + 4= 0
1 + 3 + 5= 0

Combinations:
1 + (3 OR 4) = 0
1 + 2 + 3= 0
1 + 2 + 4= 0
1 + 3 + 5= 0

21
Application of Inclusion and Exclusion Criteria
The preliminary search results were imported into EndNote reference management
software. After automatic removal of duplicates, 1101 articles were identified as a result of the
combined searches. In order to narrow the results to the most relevant articles, the titles and
abstracts were reviewed using specific inclusion and exclusion criteria. The inclusion and
exclusion criteria were updated during the last search. These criteria, along with rationale for
selecting the criteria, are summarized in Table 2.

22
Table 2
Inclusion and Exclusion Criteria
Inclusion Criteria
English language
Original research (e.g.,
controlled studies and
systematic reviews) and
reviews in peer-reviewed
journals.
Adult age 19 years and older.

Exclusion Criteria
Not available in English
Book reviews, abstracts, meeting
briefs, commentaries, letters to
editor, updates.

Rationale
Readability
Integrative literature reviews focus
on analyzing literature from
original research sources and peerreviewed journals.

Age under 19/pediatrics.

Focus on clinical context.

Focus on teaching, education, or
research.
Articles were not excluded if the
focus was on settings other than
primary care.

Review focus is on the relationship
with the patient, not the family; a
pediatric context introduces more
focus on family dynamics.
Review focus is on clinical
context.
Even though there are implications
for generalizability, there was not
enough nurse practitioner-focused
literature that focused exclusively
on the primary care setting.
Review focus is on therapeutic
relationships, not on specific skills
or clinical practices demonstrated
by nurse practitioners with no
linkage to therapeutic
relationships.
To enhance the focus on nurse
practitioners and avoid difficulties
applying physician literature to
nurse practitioners.

Focus on primary care settings
or types of patients that would
be seen in primary care.
Focused on nurse practitionerpatient relationship and/or
interactions that may reveal
information about the
therapeutic relationship.

Focused on specific element of
care (e.g., treatment advice,
consultation time).

Research conducted on nurse
practitioners.

Research not conducted on nurse
practitioners. Must not be
focused on nurses, physicians, or
other health care providers. May
include other health care
providers as comparison, but
nurse practitioners need to be a
part of the sample.
Article that reiterates the general
findings of a review article, with
no new considerations or insights
into the subject.

Individual article with findings
that are included in an
integrated review, but not
represented in the review in a
way that highlights its
importance to this literature
review question.
All years.

No date exclusions.

Avoid repetition/overrepresentation of the same
findings.

There is not as much literature
specifically for nurse practitioners,
thus limiting time of publication
would limit the search results even
further.

23
After titles and abstracts were reviewed with the inclusion and exclusion criteria, and
non-relevant articles were removed, the full text of the remaining 45 articles were reviewed and
inclusion and exclusion criteria were reapplied, in order to again improve upon the relevancy of
the results to the research question, and produce a more manageable body of literature for
focused review. After full text screening, five articles remained. The references from these five
articles were then hand-searched, in order to ensure other relevant articles were not missed. The
hand-search produced two more articles for inclusion. A summary of the full search process with
results is illustrated in Figure 1.
Figure 1.
Literature Search Strategy

24
Analysis of Final Articles
At the conclusion of the search, a total of seven articles were selected for critical analysis
and inclusion in the literature review. The analysis was executed using a literature review matrix.
Column headings in the matrix were guided by literature appraisal guidelines and content in the
matrix was guided by themes that emerged from the literature. The literature review matrix can
be found in Appendix A. Each article was appraised for methodological rigour, validity, and
strength of evidence using the Critical Appraisal Skills Programme (CASP, 2013) checklists.
The results of the analysis are presented in the next chapter.

25
Chapter Four
Findings
Seven articles were selected for inclusion in this literature review. These articles were
analyzed using a literature review matrix. The literature review matrix is provided in Appendix
A. This analysis was guided by the research question: What actions can novice nurse
practitioners take to develop and maintain therapeutic relationships with adult patients in primary
care? The literature analysis revealed four key themes regarding the actions of nurse
practitioners: (a) competence and knowledge, (b) valuing and affirming exchanges, (c) patient
engagement and reciprocity, and (d) appreciating context. The articles and findings will be
discussed in alphabetical order. A table of themes and subthemes found in each article is
provided in Appendix B. This chapter concludes with a summary of the findings.
The Nurse Practitioner-Patient Therapeutic Encounter
Bentley et al. (2016) conducted an integrative review of the key features of nurse
practitioner-patient interactions in therapeutic encounters. Ten studies were included in their
review, which represented over 900 nurse practitioners and their patients. The studies included in
this review focused on the care of older people in the community and facilities, including
primary care settings. There are many strengths to Bentley et al.’s review. Bentley et al. used
Whittemore and Knafl’s methodology that provided the tools for the detailed analysis of the
articles. The studies included were all assessed as moderate in quality, using the National
Institute for Health and Clinical Excellence’s (NICE) quality appraisal checklists, and the
analysis of individual articles was very detailed. The studies were all from the United States and
United Kingdom, so the Canadian health care context was not represented. The location may
have some effect on how nurse practitioners are perceived by patients, and the challenges for and
facilitators to the nurse practitioner-patient interaction. Bentley et al. included studies of nurse

26
practitioners in primary care settings, thus the findings are directly applicable to nurse
practitioners working in primary care. The findings of Bentley et al.’s review reveal key factors
in the therapeutic encounter that improve patient outcomes, thus help to answer the question of
how nurse practitioners can develop and maintain therapeutic relationships with patients.
Bentley et al. (2016) found that there are three key factors in the nurse practitionerpatient interaction: nurse practitioner expertise and influence of context (e.g., the clinic setting
and purpose of the visit), affirming exchange, and high levels of patient engagement. Bentley et
al. observed that patients trusted the competence of nurse practitioners who were acting as
autonomous primary practitioners. Competence was demonstrated by the giving and seeking of
information, such as biomedical information about treatments and alternatives, as well as
discussing the psychosocial aspects of the patients’ lives. Bentley et al. addressed context in
terms of the purpose of patients’ visits. Bentley et al. described affirming exchanges as the
giving of emotional support or encouragement. Affirming exchanges were the result of affirming
communication, which was characterized by positive regard, respect, trust, openness, empathy,
reciprocity, reassurance and concern or inquisitiveness into the biopsychosocial aspects of the
patients’ lives and their conditions. Bentley et al. observed that high patient satisfaction with
nurse practitioners was related to this kind of communication and the time spent with the patient.
Bentley et al. also found that, with this approach, patients were more engaged and more likely to
adhere to treatment plans. Several of the studies reviewed by Bentley et al. mentioned patients’
satisfaction with the increased time generally provided to them by nurse practitioners. This
particular finding will be discussed further by analyzing one of the articles that highlighted the
importance of time. Patient engagement was not well-described, but was reported to be increased
with the use of affirming exchanges, particularly the inquisitiveness of the nurse practitioner.

27
Although Bentley et al. (2016) found that the context of the visit impacted the type of
therapeutic encounter (e.g., highly sensitive health concerns, simple health concerns, and initial
visits for a particular concern versus repeat visits), it was noted that the other key factors of the
interaction remained the same. Thus, nurse practitioners consistently used their expertise,
affirming communication, and patient engagement across visit contexts. This particular finding
of Bentley et al. suggests a consistency of approach that may be important for nurse practitioners
in primary care. Furthermore, of all three key factors identified by Bentley et al., the key feature
of successful interactions is affirming exchanges, which seem to enhance the interaction
significantly even when the visit is more time-limited or for a more simple health concern. The
use of affirming exchanges may be the most important finding from Bentley et al., likely
contributing to developing and maintaining therapeutic relationships.
Solidarity, Alignment, and Identity Construction in Nurse Practitioner-Patient Interactions
The studies by Defibaugh (2014, 2015) were concerned with the language used by nurse
practitioners in order to achieve solidarity and alignment, and create certain practitioner and
patient identities. Defibaugh (2014) conducted an ethnographic study on how solidarity is
negotiated in interactions between nurse practitioners and patients. The study was conducted
with one nurse practitioner working as a diabetes specialist on a hospital internal medicine team,
and 20 of her patients. The patients were aged 28-82, with 13 females and seven males. The data
was collected over a period of two months and comprised audiorecordings of visits, interviews
with the nurse practitioner and her 20 patients, and ethnographic field notes. The rigor of the
research was ensured by the analysis of the actual linguistic material collected, however, the
study was quite limited since only one nurse practitioner was under consideration and Defibaugh
(2014) does not explain how the nurse practitioner was chosen. The strengths of this study lie in

28
the utilization of a multi-theoretical approach and conversation analysis as the analytical
framework. The interactions between the nurse practitioner and the patient were well-described,
with several verbatim excerpts presented, and these examples seemed consistent with
Defibaugh’s (2014) conclusions.
It is noted that the nurse practitioner in Defibaugh’s (2014) study was not practicing in a
primary care setting, so the impact of the inpatient context must be taken into consideration. The
types of interactions described by the Defibaugh (2014), such as discussing a new diagnosis and
changing medications, are similar to what is done in primary care, thus there are some
similarities in practice despite the differing contexts. The power imbalance between ill patients
and their professional caregivers is amplified in the hospital environment. This imbalance was
likely beneficial for Defibaugh’s (2014) study, as the nurse practitioner’s attempts to achieve
solidarity and alignment with her patients may have been more pronounced in this setting and
thus easier to study. Since the nurse practitioner in Defibaugh’s (2014) study works with patients
in the hospital context, her relationship with these patients is short-term. The concepts of
solidarity and alignment may look different in longitudinal relationships, such as those in
primary care. However, there is still an inherent power imbalance between patients and
practitioners in primary care.
Defibaugh (2014) found that nurse practitioners decrease the social distance between
themselves and their patients in order to allow their patients to share power, and allow patients to
identify as themselves outside of their patient identity. Defibaugh (2014) found that decreasing
the social distance creates solidarity between nurse practitioners and patients. The nurse
practitioner in Defibaugh’s (2014) study did this by using small talk, and using first-person
plural pronouns (e.g., “we” or “our”) when discussing treatment options and decision-making.
Defibaugh (2014) asserts that these techniques create a sense of shared ownership, shared role of

29
experiencer, and shared decision maker. It also encourages patients to speak and share their
narratives, showing interest in their non-patient identity. To support this, the nurse practitioner
did not interrupt narratives; instead, she enacted supportive moves (such as saying “yes”, “okay”,
and “good”). In return, the patients also used the first person plural pronouns, thus demonstrating
reciprocity. Defibaugh (2014) reasons that solidarity may be sought due to the “middle space”
position of the nurse practitioner in the traditional medical hierarchy (i.e., where the physician is
given the most power), or in the patients’ or nurse practitioners’ own views. In fact, the nurse
practitioner in this study explained that she worked more on the relationship with the patient
because she perceived that patients would not tolerate any negative interaction with her, whereas
they would tolerate more from the attending physician. The nurse practitioner felt that the
patients may ask her to leave and then she could not do her job, whereas she did not think
patients would ask the “more powerful” physician to leave. According to Defibaugh (2014),
gaining solidarity with the patient then became a way in which to provide the nurse practitioner
with more perceived power. Defibaugh (2014) did not identify how long the nurse practitioner
had been practicing in her study, so it is unknown if this perspective may be connected to the
transition period that novices go through. The nurse practitioner in Defibaugh’s (2014) study
worked as part of an internal medicine team, so this perspective on power imbalance between
nurse practitioners and physicians may not be shared in the same way in primary care settings.
However, the significance of this particular finding will be explored more in the discussion
chapter.
Defibaugh (2015) expanded on her previous study and conducted an ethnographic study
for her dissertation on identity construction in the interactions between nurse practitioners and
patients, with the aim to identify the specific linguistic moves and stylistic choices that nurse
practitioners use in communication with patients. This study incorporated the analysis of 48

30
medical visits with five different nurse practitioners involving the investigation of the
audiorecordings of visits and interviews with the nurse practitioners and patients. This time, only
one hospital-based nurse practitioner was a part of the sample, with four other nurse practitioners
from different community clinics, three of which were men’s health primary care clinics. Using
an ethnographic discourse analytic methodology, Defibaugh (2015) utilized Agha’s theory of
figures of personhood to study the ways in which nurse practitioners constructed the identity of
caring provider. Defibaugh (2015) also studied the ways in which patients construct their own
identities, though this section of her dissertation will not be discussed here due to this review’s
focus on the actions of nurse practitioners. Defibaugh (2015) strengthened her study by using
emic and etic viewpoints and the ethnographic analytical discourse approach. Defibaugh (2015)
satisfied rigour by using the actual linguistic material upon which Defibaugh (2015) studied the
communicational process of the nurse practitioners and patients, and keeping a very detailed and
thorough description of her data collection and analysis techniques. Defibaugh (2015) also
provided information on whether the visits were first-time visits or follow-up visits, and the
length of time of the visits. Many verbatim excerpts of the interactions were presented, including
tables identifying specific linguistic choices within verbatim excerpts (such as singular and
plural pronouns). Thus, this writer verified Defibaugh’s (2015) interpretations, and came to the
same or similar conclusions.
As a result of the analysis, Defibaugh (2015) noted that nurse practitioners are able to
balance both instrumental and interactional goals to construct the identity of a “caring and
competent” provider. Alignment with the caring provider identity was accomplished by using
linguistic moves of solidarity. These linguistic moves included small talk, inclusive first person
pronouns, hedging and indirect speech. Alignment with the competent provider identity was
accomplished by attending to their occupational and professional responsibilities, recognizing a

31
responsibility to patients, and creating alignments to organizations and institutions. Nurse
practitioners created a comfortable communicational atmosphere for the patients by using lay
terms to explain medical information to the patient, and following the medical checklist though
sometimes allowing the topic to deviate based on patient’s responses, directing attention to what
the nurse practitioner felt was important while still addressing patient’s concerns. Thus,
Defibaugh (2015) concluded that in communication with patients, nurse practitioners balance
their interpersonal goals (using caring identity) and instrumental goals (using competent
identity), which resulted in patient satisfaction and reciprocity. In terms of patient engagement,
Defibaugh (2015) reasoned that nurse practitioners demonstrate patient engagement by
encouraging patients to share their narratives, getting to know their patients beyond their identity
as patients, and involving them in decision-making. Defibaugh (2015) reported that these
patients were very satisfied with these nurse practitioners and rated them very highly.
Furthermore, Defibaugh (2015) referenced the relevance of her findings to developing long-term
relationships with patients, like those seen in primary care. Thus, these engaging behaviours on
the part of the nurse practitioner may aid the maintenance of therapeutic relationships.
Defibaugh (2014) provided insights into the concepts of solidarity and alignment in the
therapeutic relationship that are hinted at in other articles, but not explicitly described.
Defibaugh’s (2015) descriptions of techniques used to create solidarity and alignment have some
overlapping themes and similarities with Bentley et al.’s (2016) key factors. Defibaugh’s (2014,
2015) description of linguistic moves, balance of interpersonal goals with instrumental goals,
creation of a caring identity, and moves to create solidarity and alignment seem to have
conceptual overlap with Bentley et al.’s description of affirming exchanges. The overlap is most
obvious in the descriptions of reciprocity, interest in the biopsychosocial aspects of the patient’s
lives, and patient engagement. Defibaugh (2014, 2015) and Bentley et al. also both describe

32
competence as important in the nurse practitioner-patient interaction. These overlapping themes
increase the validity of the shared findings.
The Empathetic Partnership Framework
Flemmer, Dekker, and Doutrich (2014) created a framework for nurse practitioners in
primary care to create effective and therapeutic partnerships with patients. Flemmer et al.’s
Empathetic Partnerships framework was influenced by the work of US sociologist Dr. Brenè
Brown and “the tenets of cultural safety” (Flemmer et al., 2014, p. 546). In particular, the
framework draws on Brown’s Acompañar theory of professional helping, and her work on
shame resilience, vulnerability, authenticity, and empathy. These theories, along with a focus on
cultural safety, give strength to the framework being used with marginalized patients. The
framework was developed by nurse practitioners in primary care. Although Flemmer et al.
encourage broad use of the framework, the framework seems to have particular relevance for
vulnerable patients, as they use a marginalized patient population (women who have sex with
women) as an example. The focus on marginalized and vulnerable patients may be of particular
relevance to nurse practitioners, who are often employed through initiatives aimed to provide
health care to these underserved patients (Sangster-Gormley & Canitz, 2015). However, this
focus may also limit its use in general primary care settings. Another weakness of this
framework is that there has been no research to support the framework or test its use in practice.
However, a possible strength of this framework is that its key elements reflect the four main
themes from the findings of this literature review.
In Flemmer et al.’s (2014) Empathetic Partnership framework, there are six elements:
reflection, environment, language, knowledge, partnership, and empathy. The reflection element
involves nurse practitioners’ continuous reflection on their own biases, cultures, power, and
privilege, and questioning of roles, assumptions, filters, and perceptions. The environment

33
element consists of the physical space in which the interaction between nurse practitioner and
patient occurs; attention is paid to displays of art and information, such as posting a
nondiscrimination policy. Flemmer et al. recommended posting a nondiscrimination policy, and
even including health care advertisements in gay media and other welcoming promotional
materials. The exemplar population for Flemmer et al.’s framework was women who have sex
with women, so these specific recommendations make sense in this context. The language
element emphasizes the use of nondiscriminatory and nonjudgmental language with attention to
assumptions. The knowledge element encourages nurse practitioners to sustain a knowledge base
for diverse populations and consider the individual patient within given statistical tendencies.
The last element is partnership and empathy. This framework uses the term ‘partnership’ to
describe the relationship between nurse practitioner and patient. The partnership element
encourages nurse practitioners to shift the power dynamic between themselves and patients.
Within a partnership, patients are experts on themselves, and nurse practitioners focus on the
needs and desires identified by the patient. To promote partnership, Flemmer et al. encourage
nurse practitioners to be nonjudgmental, open, and encouraging of patients. To demonstrate
empathy, the nurse practitioner understands the patient’s feelings and world view, is
nonjudgmental, and communicates that understanding to the patient.
The use of the term ‘partnership’ in Flemmer et al.’s (2014) framework, instead of the
term ‘therapeutic relationship’ seems to be aimed at emphasizing the importance of patient
engagement and reciprocity, which was also found to be one of the main themes of this literature
review. The other key elements of Flemmer et al.’s framework also reflect the four main themes
of this literature review. The elements of reflection and knowledge can be included in this
review’s competence and knowledge theme; the key elements of language and empathy can be
included in this review’s valuing and affirming exchanges theme; the key element of partnership

34
can be included in this review’s patient engagement theme; and the key element of environment
can be included in this review’s context theme. Flemmer et al. emphasized the importance of
addressing the physical environment more than any of the other authors included in this review,
though this was also mentioned by Bentley et al. (2016), and Defibaugh (2014, 2015). Each
element of Flemmer et al.’s framework fits in well with the themes from the literature, thus this
framework may provide a basis on which to discuss how to develop and maintain therapeutic
relationships with patients.
Essential Meanings of Nurse Practitioners’ Lived Experiences Interacting with Patients
Kleiman (2004) explored the lived experience and meaning of nurse practitioners’
interactions with patients. In this phenomenological study, Kleiman conducted interviews with
six nurse practitioners working in a variety of settings. The nurse practitioners interviewed
included a psychiatric nurse practitioner in community mental health, an adult nurse practitioner
in a hospital cardiac unit, a family nurse practitioner in a college student health center, a geriatric
nurse practitioner in a long-term care facility, an adult nurse practitioner in a private urology
practice, and a pediatric nurse practitioner in partnership with a physician. Kleiman’s study had a
very small sample size, but this was appropriate for the phenomenological nature of the study.
Kleiman used systematic criteria to evaluate the described experiences, which established the
rigor of this qualitative work. The verbatim excerpts provided by Kleiman accurately illustrate
the essential meanings that she identified. Although the study was not focused exclusively on
nurse practitioners in primary care, it did include the perspective of a family nurse practitioner
and two nurse practitioners working in population-focused primary care. This study was
included in Bentley et al.’s (2016) review, but is included here in order to better represent the
nurse practitioner’s perspective. Kleiman’s study is one of two studies included in this review

35
that explored nurse practitioners’ own reflections on their work, providing this review with a
perspective that was not directly observational or patient-focused.
Kleiman (2004) found that nurse practitioners assigned many meanings to their
interactions with patients. Kleiman states that these interactions evolved within the context of the
relationship between the nurse practitioner and patient. Kleiman found that nurse practitioners
focused on their relationships with patients (which sometimes extended to patients’ family, but
the focus was on the patient), the meanings, and understandings that stem from this relationship
that are not necessarily related to outcomes of health-related interventions. In other words, nurse
practitioners were relationship-oriented rather than purely disease-oriented. One nurse
practitioner in Kleiman’s study emphasized, “ ‘It’s the person-to-person exchange that is the
most important aspect of patient care. Make them comfortable so you can communicate, find out
what their needs are and take care of them’” (2004, p. 265). Kleiman reported that the
interactions between nurse practitioners and patients were unhurried, open, and attentive, despite
time concerns. Kleiman identified the following meanings from the interactions between nurse
practitioners and patients: openness, connection, concern, respect, reciprocity, competence, time,
and professional identity. These meanings reflect qualities that define valuing and affirming
exchanges, such as attentiveness, availability, welcoming demeanor, authentic presence, values,
and evocative interactions.
Some of the essential meanings discovered by Kleiman (2004)– particularly connection,
concern, respect, and reciprocity– are reflected in Bentley et al.’s (2016) identification of
affirming exchanges and patient engagement as key factors in the nurse practitioner-patient
interaction. However, Bentley et al. did not fully capture the underlying finding that nurse
practitioners consciously self-manage during patient interactions and engage in self-reflection.
Kleiman thought that competence was demonstrated by nurse practitioners through their ability

36
to understand their own personal and professional capabilities and their ability to identify and act
to meet patients’ needs. This perspective integrates self-reflection with competence. This finding
that self-reflection and self-management are integral to the nurse practitioner-patient interaction
also underlies Defibaugh’s (2014, 2015) studies and is a key element in Flemmer et al.’s (2014)
framework. Kleiman remarks that the “connection [between nurse practitioner and patient]
flourishes in an ongoing reciprocal process of collaborative engagement of the patient’s healthrelated concerns” (p. 268), and this connection is sustained over time in an intimate, ongoing
relationship. This remark by Kleiman is important because it signifies not a singular exchange,
but rather a process that develops over repeated interactions that occur during the relationship. It
suggests that reciprocity, or patient engagement, is one of the most important features in
establishing longitudinal relationships with the patients, a finding that is shared with Defibaugh
(2014, 2015) and Flemmer et al. (2014).
Nurse Practitioner-Patient Interaction as Resource Exchange
Whereas Kleiman (2004) focused on the connections made with patients on an emotional
level, Koeniger-Donohue (2007) focused on the resource exchange between nurse practitioners
and patients. Her exploratory descriptive study aimed to explore nurse practitioner-patient
encounters from the nurse practitioner’s perspective using a resource exchange paradigm.
Koeniger-Donohue explained that “exchange theorists deal with valued resources that persons
expect and receive which contribute to and build the exchange relationship” (p. 1051). The focus
of the study was on what resources nurse practitioners anticipated they would provide to their
patients before a visit, the resources that were actually provided, and the nurse practitioner’s
perception of what transpired after the visit. The study by Koeniger-Donohue was conducted
with two expert nurse practitioner participants and eight patient participants in a women’s health
practice. Data consisted of pre- and post-encounter interviews with the nurse practitioners,

37
audio-recordings of the full encounters, and field notes made by the researcher. All the patients
were middle-aged females. Koeniger-Donohue selected the nurse practitioners in her study
purposely for their excellent reputations, so the practices of these expert nurse practitioners may
not be typical of most nurse practitioners. The study is relevant to primary care as it was
conducted in a primary care setting, with a population focused on women’s health. KoenigerDonohue used Foa and Foa’s Resource Exchange Theory as a framework for interpreting her
data, but she did not limit her interpretation when her findings did not fit within Foa and Foa’s
classes of resources. By adding an “affirmation” resource category in addition to Foa and Foa’s
standard categories, Koeniger-Donohue provided a better representation of her findings.
Koeniger-Donohue’s study was included in Bentley et al.’s (2016) review, but is included here in
order to more fully capture the patient engagement theme. While the focus of KoenigerDonohue’s study was not necessarily on the therapeutic relationship between nurse practitioners
and patients, her findings have implications for relationship development, particularly regarding
factors that reinforce the relationship.
Koeniger-Donohue (2007) observed five out of six of Foa and Foa’s Resource Exchange
Theory classes of resources between nurse practitioners and their patients: services (activities
that affect the body and include labour for another); information (advice, opinions, instruction);
goods (tangible products); love (an expression of affectionate regard, warmth, or comfort); and
status (an evaluative judgment that conveys prestige, regard, or esteem). Koeniger-Donohue
noted that she did not see the resource class of money (currency or a standard unit of exchange)
used in any of the nurse practitioner-patient interactions. Based on her observations, KoenigerDonohue added a resource category called affirmation, which included the provision of
reassurance, reinforcement, support and feedback. Koeniger-Donohue also noted that nurse
practitioners more easily used the full range of resources in established relationships (compared

38
to new relationships). Although the focus of her study was on the nurse practitioner’s perspective
of what was given to the patient, it would be interesting to explore nurse practitioner-patient
encounters from the patient’s perspective using a resource exchange paradigm, in order to obtain
complementary information about what resources patients expect, and how patients perceive the
interactions using the same resource-exchange paradigm.
Though the categories of resources described in Koeniger-Donohue (2007)’s study were
represented in the findings of Bentley et al.’s (2016) review, Bentley et al. did not emphasize the
perspective that the resources used in interactions change depending on the stage of the
relationship. This particular context factor was touched on by Defibaugh (2014, 2015). This
perspective acknowledges that there are differences in how nurse practitioners may navigate
resources during the initial establishment of the relationship versus an established relationship.
Patients’ Assessments of Consulting a Nurse Practitioner
Williams and Jones (2006) conducted a qualitative study with the aim to explore patients’
views about consulting with a primary care nurse practitioner. Williams and Jones conducted indepth interviews with ten patients immediately after their consultation with one particular nurse
practitioner. The patients were between the ages of 19-76, half were men, and half were women.
It is noted that this study was a part of a wider case study conducted in the UK, and Williams
and Jones emphasized that their findings reflected the findings of larger studies comparing nurse
practitioners to general practitioners in terms of patient satisfaction. This study was conducted in
primary care, thus is directly relevant to nurse practitioners in primary care. Williams and Jones’
study was included in Bentley et al.’s (2016) review, but is included here to further describe the
time factor in patient visits. This study is valuable as it uncovers patients’ perspective on nurse
practitioners’ consultations, unlike Kleiman (2004) and Koeniger-Donohue (2007), whose
studies focused on the perspectives of practitioners.

39
Williams and Jones (2006) found that all but one patient appreciated the extra time given
by the nurse practitioner in the consultation in order to discuss all the issues. When the details of
this visit were reviewed, it was found that the one patient who did not indicate appreciation for
extra time was a 76 year-old male patient who visited for an emergency chest problem, whereas
other patients appeared to be visiting for chronic conditions or minor acute infections. This
finding may be explained due to the presumed emergent nature of this concern, thus efficiency
may have been preferred over extra time. Otherwise, Williams and Jones found that patients
appreciated having time to attend to complex emotional needs, discuss factors affected by their
problem (such as family, work, and relationships), and appreciated the style of consulting,
questioning, and discussing of treatment options other than prescriptions. These findings seem to
indicate that it was not the extra time that was appreciated by patients, but that the practitioner
went into more depth with the consultation as a result of the time given.
In Williams and Jones’ (2006) study, patients with complex or chronic conditions seemed
to have more satisfaction with longer visits. However, time is likely not the true reason for
satisfaction. The importance of time as context was also mentioned by Bentley et al. (2016),
Defibaugh (2014, 2015), Kleiman (2004), and Koeniger-Donohue (2007), though time was not
explored in depth. Some of the patients’ comments from Williams and Jones’ study were not
about time at all; instead, they commented on the nurse practitioner’s thoroughness, less
intimidating manner, lack of forceful directives, good listening, and flexibility with treatment
approaches that met the patients’ needs and upheld their values. These comments also reflect the
competence and knowledge of nurse practitioners that was identified as a key factor by Bentley
et al., Kleiman, and Koeniger-Donohue. Several of the patient comments in Williams and Jones’
study reflect or demonstrate the other key factors of the nurse practitioner-patient interaction
identified by Bentley et al. (2016); the essential components of Flemmer et al.’s (2014)

40
Empathetic Partnership model; the meanings discovered by Kleiman (2004); and the classes of
resources described by Koeniger-Donohue (2007). Overall, Williams’ and Jones’ study
contributes to this review by adding more of the patient’s perspective and highlights the time
factor in patient consultations.
Summary
In summary, this analysis has provided a critical review of the findings of the seven
articles selected for inclusion in this literature review. This literature addressed the features of
the nurse practitioner-patient interaction (Bentley et al., 2016); how solidarity is negotiated in
nurse practitioner-patient interactions (Defibaugh, 2014); how identity is constructed in nurse
practitioner-patient interactions through specific linguistic moves and stylistic choices
(Defibaugh, 2015); what meaning nurse practitioners give to their lived experiences of their
interactions with patients (Kleiman, 2004); how nurse practitioners view and conduct patient
encounters from a resource exchange paradigm (Koeniger-Donohue, 2007); and patient views
about consulting with a nurse practitioner in primary care (Williams and Jones, 2006). In
addition, the Empathetic Partnership model from Flemmer et al. (2014) was presented for
consideration.
In the findings, the authors described factors, elements, concepts, resources, and
meanings within nurse practitioner-patient interactions. These factors, elements, concepts,
resources, and meanings resulted in actions aimed at developing and maintaining the therapeutic
relationship on the part of the nurse practitioners in the studies. For example, Defibaugh (2014)
identified solidarity as an important concept in nurse practitioner-patient interactions. Defibaugh
(2014) then described specific ways nurse practitioners established solidarity; the use of small
talk was one of the actions that nurse practitioners took to establish solidarity. Another example
is the identification of affirmation as a resource by Koeniger-Donohue (2007). Koeniger-

41
Donohue then described ways that nurse practitioners provided affirmation; using reassurance,
reinforcement, support, and feedback were actions that nurse practitioners took to provide
affirmation. A table of the factors, elements, concepts, resources, or meanings identified from
each article is provided in Appendix C. The next chapter of this literature review synthesizes the
background evidence with the literature search findings to identify what actions novice nurse
practitioners can take to develop and maintain therapeutic relationships with adult patients in
primary care.

42
Chapter Five
Discussion
The wide effects that therapeutic relationships can have on patients’ health outcomes
underscores the importance for novice nurse practitioners to develop and maintain these
relationships in order to maximize patients’ health outcomes. Through this literature review, the
topic of therapeutic relationships between nurse practitioners and patients was explored, in order
to better understand how the context of primary care and changes in professional education and
focus might change how novice nurse practitioners develop and maintain therapeutic
relationships. In addition, the shifting practice environment of nurse practitioners and its
associated challenges may impact how novice nurse practitioners are able to develop and
maintain therapeutic relationships with patients in primary care. An integrative literature review
was conducted, guided by the following question: What actions can novice nurse practitioners
take to develop and maintain therapeutic relationships with adult patients in primary care? A
combination of qualitative and quantitative studies concerning nurse practitioner-patient
interactions was examined. This chapter answers the research question. The chapter begins with
a review of the key findings. This is followed by a discussion of the implications and proposed
recommendations for clinical practice and future research. The implications and
recommendations focus on the practice environment of nurse practitioners in primary care in
British Columbia. Next, the limitations of this literature review are discussed. To complete this
chapter, a final summary and conclusion are provided.
Key Findings
The literature analysis revealed four key themes regarding the actions of nurse
practitioners: (a) competence and knowledge, (b) valuing and affirming exchanges, (c) patient
engagement and reciprocity, and (d) appreciating context. Within these themes, several actions

43
taken by nurse practitioners are identified that may help novice nurse practitioners to develop
and maintain therapeutic relationships. A summary table of the actions identified by theme is
provided in Table 3 below. These actions will now be presented and discussed in light of the
literature reviewed and the context of the question.

44
Table 3
Summary of Actions by Theme
THEMES
Competence
and
Knowledge

Valuing and
Affirming
Exchanges

Patient
Engagement
and
Reciprocity

Appreciating
Context

ACTIONS
- Uses/provides expertise and knowledge with/for patients 1, 2, 3, 4, 5, 6
- Aligns with the competent provider identity by attending to occupational and
professional responsibilities and creating alignments to organizations and institution 3, 5
- Balances instrumental and interactional goals in patient consultations (i.e. follows the
medical checklist but allows the topic to deviate based on the patient’s responses) 3
- Reflects on own biases, cultures, power, and privilege 4, 6
- Reflects on own personal and professional capabilities and ability to identify and act
to meet patient needs 5
- Questions roles, assumptions, and perceptions 4
- Sustains a knowledge base for diverse populations 4
- Considers individual patients within given statistical tendencies 4
- Provides affirming exchanges by giving emotional support and encouragement
(empathy), showing concern, providing reassurance and reinforcement, giving full
attention, making self available, being welcoming, and eliciting feedback 1-7
- Aligns with the caring provider identity and creating solidarity by using small talk and
first-person pronouns (e.g., ‘we’ or ‘our’), especially when discussing treatment options
and engaging patients in decision-making 2, 3
- Demonstrates inquisitiveness/curiosity into patients’ lives 1, 2, 3, 5
- Avoids interrupting narrative; instead, uses supportive moves to encourage narratives,
such as saying ‘yes’, ‘okay’, and ‘good’ 2, 3
- Creates a comfortable communicational atmosphere by using lay terms that patients
can understand 3
- Incorporates culturally safe actions, such as using nondiscriminatory and
nonjudgmental language with attention to assumptions, avoiding diminishing or
demeaning a person’s culture*4, and avoiding intimidation 4
- Demonstrates positive regard and openness with all patients 1, 4, 5
- Encourages patients to share their narratives 1, 2, 3, 5, 6
- Gets to know patients beyond their identity as patients *1, 2, 3
- Discusses other life areas that are affected by the patient’s problem (e.g., family,
work, relationships) 1, 2, 3, 7
- Promotes partnership by communicating an understanding of the patient’s feelings
and worldview to the patient in a nonjudgmental way 4
- Involves patients in decision-making and respects patient self-determination 1-7
- Discusses treatment options with patients, especially options other than prescriptions7
- Consider context and purpose of visit 1
- Creates a culturally safe environment by displaying appropriate art and information in
the care setting 4
- Identifies vulnerability 4
- Maintains unhurried consultations despite time concerns 2, 5, 6, 7
- Takes as much time as needed to provide an in-depth, thorough consultation5, 6, 7

1. Bentley et al. (2016); 2. Defibaugh (2014); 3. Defibaugh (2015); 4. Flemmer et al. (2014); 5. Kleiman (2004); 6.
Koeniger-Donohue (2007); 7. Williams and Jones (2006).

45
The key findings and identified actions reflect the competencies for nurse practitioners in
British Columbia, but specific actions that novice nurse practitioners should take are not clear
within the competencies (CRNBC, 2010). Novice nurse practitioners are expected to be
competent, but practicing in the new setting of primary care requires novice nurse practitioners
to act in ways that may be different from registered nursing practice. The actions listed under the
competence and knowledge theme can help novice nurse practitioners meet the competencies
related to incorporating knowledge and providing information and education. There are specific
actions that novice nurse practitioners can take to meet these competencies, such as sustaining a
knowledge base for diverse populations and considering patients as individuals. Novice nurse
practitioners might overlook certain actions when trying to meet these competencies, such as the
actions around self-reflection and questioning assumptions. In addition, novice nurse
practitioners may not feel competent in all visits to enact certain competencies in practice, such
as incorporating knowledge from a variety of subjects to perform health assessment, make
diagnoses, and provide therapeutic management. This will be discussed further in implications
and recommendations.
The actions listed under the valuing and affirming exchanges theme can help novice
nurse practitioners meet the competencies related to communication skills, coalition building,
and patient education and counseling. The actions that novice nurse practitioners can take to
meet the competencies related to communicating with patients about health assessment findings
and diagnosis and applying their advanced knowledge and skills in communication and coalition
building include giving emotional support and encouragement (empathy), showing concern,
providing reassurance and reinforcement, giving full attention, making oneself available, being
welcoming, eliciting feedback, using small talk and first-person pronouns, avoiding interrupting,
using nondiscriminatory and nonjudgmental language, demonstrating positive regard and

46
openness, and avoiding intimidation. There are other specific actions that novice nurse
practitioners may overlook when trying to meet the communication and patient education
competencies, such as demonstrating inquisitiveness or curiosity into patients’ lives. This
particular action allows a better understanding of patients’ perspectives and supports, thus
resulting in the patient feeling known and being provided with education that takes their personal
lifestyle into account. Novice nurse practitioners may be curious about their patients’ lives but
not realize that this helps meet competencies for practice. The actions under valuing and
affirming exchanges also reflect Peplau’s (1992) patient-centered approach to therapeutic
relationships, Charlton et al.’s (2008) description of patient-centered communication, and
support the assertion that nurse practitioners are attentive and caring (Sangster-Gormley &
Canitz, 2015).
The actions listed under the patient engagement and reciprocity theme can help novice
nurse practitioners meet the competencies related to exploring therapeutic options with patients,
determining care options in negotiation with patients, evaluating and revising care plans with
clients, and creating an environment that maximizes patient participation. The actions that novice
nurse practitioners can take to determine care options and create an environment that maximizes
patient participation include encouraging patients to share their narratives, getting to know
patients beyond their patient identity, and discussing other life areas that are affected by the
patient’s problem. These actions help novice nurse practitioners explore therapeutic options with
a patient while considering implications for the individual patient that are based on the patient’s
perspectives. These actions also help novice nurse practitioners educate using appropriate
teaching and learning strategies, and coach and counsel patients while considering their personal
responses. The actions that novice nurse practitioners can take to negotiate with patients and
encourage active participation when prescribing drug therapy, determining care options, and

47
therapeutic interventions based on patient goals and preferences include promoting partnership,
involving patients in decision-making, discussing treatment options, and respecting patient selfdetermination. The actions listed under patient engagement and reciprocity also take into account
the values of patients in primary care (Laberge et al., 2014).
The actions listed under the appreciating context theme can help novice nurse
practitioners meet the competencies related to creating an environment for effective
communication and learning, and providing culturally competent care. The actions that novice
nurse practitioners can take to meet these competencies include displaying appropriate art in the
office, using nondiscriminatory and nonjudgmental language with attention to assumptions,
avoiding diminishing or demeaning a person’s culture, and avoiding intimidation. Some of these
actions are listed under other themes, but also relate to appreciating context. Because novice
nurse practitioners are still solidifying many competencies, they might overlook certain actions
when trying to meet these competencies, such as maintaining unhurried consultations despite
time concerns. The competencies for nurse practitioners do not mention anything specifically
about timing of visits, though providing adequate time for visits likely facilitates the competency
of teaching and maximizing client participation and control of their own health. In addition, the
competencies do not particularly consider how the practice environment affects nurse
practitioners’ ability to enact the competencies.
There are several important differences in the findings of this review compared to the
findings of Bentley et al.’s (2016) review. While the four key themes of this review are
essentially the same as Bentley et al.’s three key factors, this review has greater focus on the
practical application of the findings, which resulted in greater detail in regards to actions that
novice nurse practitioners can take to develop and maintain therapeutic relationships with
patients in primary care. For example, the inclusion of Defibaugh’s (2014, 2015) articles in this

48
review allowed for greater description of linguistic choices that aid valuing and affirming
exchanges. In addition, this review focuses on novice nurse practitioners and clinical
recommendations that consider practice challenges.
Implications and Recommendations for Clinical Practice
A table summarizing the implications and recommendations for clinical practice can be
found in Appendix D.
Professional identity. Since nurse practitioners’ professional identity can shape
interactional patterns between patients and themselves (Defibaugh, 2015), the new and
developing identity of a novice nurse practitioner deserves attention. The new role of novice
nurse practitioners involves changes to occupational and professional responsibilities, new
knowledge and skills, as well as new organizational and institutional alignments. Novice nurse
practitioners may already have a clear alignment with the caring provider identity, but in their
new role in primary care, they may have a more tenuous alignment to the competent provider
identity. Thus, actions like using their new expertise and knowledge with patients in primary
care may initially be more difficult. Novice nurse practitioners may also identify concerns about
competence upon reflecting on their capabilities, and may question their ability to identify and
act to meet patient needs. A novice nurse practitioner who portrays an image of poor selfconfidence may pass this perception onto patients as an image of nurse practitioners in general,
thus negatively impacting the therapeutic relationship.
Novice nurse practitioners’ identity may also be affected by how the context of primary
care or responsibilities of providing medical care changes power dynamics in their relationships
with patients. In Defibaugh’s (2014) study, the power imbalance between nurse practitioners and
patients was exaggerated by the hospital setting. For nurse practitioners in primary care, the
power imbalance between themselves and patients may be less in the community setting, yet

49
novice nurse practitioners may feel it more intensely due to the recent transition to their new
professional responsibilities. Novice nurse practitioners may feel more uncomfortable with this
newfound sense of increased professional power and/or authority and its potential to increase the
social distance between themselves and patients. Or, novice nurse practitioners may consciously
or unconsciously use their new authority to be more directive of patients, instead of engaging
patients and involving them in decision-making.
Recommendations. To address problems with professional identity, novice nurse
practitioners can examine and use the list of actions in Table 3 to reflect on their own actions in
practice. Self-reflection informs nurse practitioners’ future interactions with patients, providing
insights that are valuable to developing and maintaining therapeutic relationships over time and
promoting self-awareness. Self-reflection should be a daily practice, whereby novice nurse
practitioners reflect on patient visits in regards to all four key themes of this literature review as
guidance, identify issues, and create actions to address the issues. Novice nurse practitioners
could seek support from their nurse practitioner colleagues, mentors, and leaders to practice or
discuss these actions. Nurse practitioner mentors or leaders could help novice nurse practitioners
incorporate these actions into their formal learning plan, and nurse practitioner colleagues may
be willing to act-out patient counseling cases with novice nurse practitioners to practice certain
actions. Practice will improve novice nurse practitioners’ skill and self-confidence with these
actions, thus helping to develop and maintain therapeutic relationships with patients. Networking
with other nurses by creating alignments to professional support organizations or groups (e.g.,
British Columbia Nurse Practitioner Association and/or practice-based small group learning
programs or more informal journal/case review groups) could also provide opportunities for
novice nurse practitioners to practice these actions and become more comfortable with their new
professional identity.

50
Solidarity. Defibaugh (2014) thought that gaining solidarity with patients was a way in
which nurse practitioners were able to demonstrate more perceived power in their new roles. If
this is true, gaining solidarity as a way to demonstrate more power may allow nurse practitioners
to align more with the competent provider identity, thus contributing to nurse practitioner selfconfidence. Yet, the way nurse practitioners were observed to negotiate power with patients
seems to be more closely related to valuing and affirming exchanges, as it was done in ways that
engaged, reassured, and encouraged patients. However, in gaining solidarity with patients, the
question arises as to whether this solidarity is in danger of being achieved at the expense of
interprofessional relationships. If patients perceive themselves in solidarity with nurse
practitioners, but not with other providers, this may create an us/them dynamic with other
providers. Essentially, this risks becoming favoritism, which violates professional boundaries
and fails to uphold the nursing standards set by the College of Registered Nurses of British
Columbia. This favoritism can also limit patients’ ability to create therapeutic relationships with
other providers at the expense of one all-encompassing relationship, which is harmful because
nurse practitioners and physicians in primary care often need to make referrals to other healthcare providers. Furthermore, if other providers notice this us/them dynamic, nurse practitioners’
ability to collaborate with other providers may be disrupted, as other providers will begin to view
nurse practitioners in opposition to them. Hence, too much solidarity may exacerbate preexisting
issues with quality of nurse practitioner-colleague relationships and cause further confusion for
colleagues’ understanding of nurse practitioners’ role.
Recommendations. When aligning with patients for solidarity, the ‘we’ of solidarity
should be extended not just to the nurse practitioner-patient team, but also to the health care team
as a whole. Novice nurse practitioners in primary care can still create solidarity between
themselves and patients, but need to be mindful to not create distance between themselves and

51
other providers. When sharing patient care with other nurse practitioners and/or physicians in the
same office or on different teams, the novice can make reference to the other providers when
using the term “we”. For example, the novice nurse practitioner might say, “The physicians,
other nurse practitioners, other health care team members, and I here at the primary care clinic
are working together with you, your family, and the senior’s clinic. Collectively, we will help to
achieve your goal of remaining at home.”
Role ambiguity. Role ambiguity can cause difficulties in understanding the changes to
occupational and professional responsibilities. In addition, this role ambiguity can also
contribute to strained relationships with other providers, thus limiting support for novice nurse
practitioners. Without support from interprofessional colleagues, managers and other staff,
patient care may be impacted, thus therapeutic relationships may be hindered between nurse
practitioners and patients. Role ambiguity could be passed on to patients as well. When patients
are seen in collaborative practice settings in primary care where patient rosters are shared, other
practitioners may provide patients with inadvertently false information about the role of the
nurse practitioner. Patients may even perceive that nurse practitioners who work in primary care
offices with physicians are not autonomous, resulting in a more negative view of nurse
practitioners, thus affecting nurse practitioners’ ability to develop and maintain therapeutic
relationships with patients. This lack of understanding about the role of nurse practitioners in
primary care may also be reinforced by the limitations imposed by the lack of long-term funding
model for nurse practitioners in British Columbia and other practice challenges.
Recommendations. Role ambiguity may dissipate as more time passes and nurse
practitioners become more integrated in the British Columbia health care system. For now, some
of the actions that help develop and maintain therapeutic relationships with patients can also
improve nurse practitioner role clarity. Reflecting on their professional capabilities can help

52
novice nurse practitioners improve role clarity for themselves. Using their expertise and
knowledge and creating alignments to organizations and institutions can help novice nurse
practitioners improve nurse practitioner role clarity for others. When starting a new position,
novice nurse practitioners can use their expertise and knowledge to talk with colleagues about
their experiences with nurse practitioners, and/or attend a staff meeting to introduce themselves
and explore staff/colleague perceptions and understanding about nurse practitioners. Novice
nurse practitioners can align with their nurse practitioner practice leader to discuss education for
physician colleagues through partnership with the local division of family practice or medical
advisory committee, or the provincial general practice services committee. Nurse practitioner
practice leaders may also be able to develop and facilitate education for health authority
leadership and specialists, perhaps through the distribution of health-authority wide notices about
the addition of nurse practitioners to their teams and how this impacts other practices and
referrals for their services.
Novice nurse practitioners can also consider aligning with the British Columbia Nurse
Practitioner Association to further the discussion on nurse practitioner role clarity with
government, interdisciplinary team members, and patients. By evaluating and/or redefining the
purposes, priorities, functions, and tasks of primary care, the identified functions and tasks can
then be aligned into roles and positions for nurse practitioners that are matched to their skills and
capabilities. Novice nurse practitioners can educate themselves about and advocate for funding
models that facilitate better understanding of the contributions and role of nurse practitioners in
the health care system. Different models may be better suited for different areas, depending on
population and provider size and characteristics, and resources. The British Columbia Nurse
Practitioner Association recently published a document titled Primary Care Transformation in
British Columbia: A New Model to Integrate Nurse Practitioners (Prodan-Bhalla & Scott, 2016),

53
that nurse practitioners can read to familiarize themselves with some of the models that are
proposed, and to advocate for a model that will work in their practice. Novice nurse practitioners
in British Columbia can become involved at advocating at whatever level they are comfortable,
including discussing practice issues (e.g., rigid performance measures) with colleagues, practice
leaders, or management (alone or with practice or colleague support); participating in formal
practice surveys; providing feedback to the British Columbia Nurse Practitioners Association;
and lobbying government.
Patient empanelment. Some challenges for novice nurse practitioners are employer,
position, or location specific, such as whether patients can be empaneled by the nurse
practitioner, size of patient panel or volume of patient visits, and characteristics of the patient
panel. Nurse practitioners in primary care do not need to be able to empanel their own patients in
order to develop and maintain therapeutic relationships, but novice nurse practitioners may have
more difficulty with patient engagement and reciprocity if they feel they have been empanelled
too many patients. Novice nurse practitioners may not feel that they have enough time for some
actions; for example, getting to know their patients beyond their patient identity, discussing other
life areas that are affected by the patient’s problem, and involving patients in decision-making.
The pressure to see more patients may also cause novice nurse practitioners to have some
difficulty with valuing and affirming exchanges, specifically using small talk and encouraging
patient narratives.
Recommendations. A fair caseload will vary depending on community size, supports,
and population needs. In order to advocate to their employers for a well-rationalized and fair
caseload, novice nurse practitioners can look to research for evidence regarding fair caseloads
for nurse practitioners in primary care. Novice nurse practitioners can then discuss adequate time

54
for patient visits with site managers, colleagues, or employers. The exact number of patients or
visits per day will be variable between nurse practitioners, depending on setting, complexity,
patient needs/wants, and experience level. A plan for a fair caseload for a novice nurse
practitioner may include more administration time at the outset, a few call-backs for some
patients, or longer visits with certain patients for the first few months. Novice nurse practitioners
may find it helpful to connect with colleagues through their local community of practice and/or
the new British Columbia Nurse Practitioners Association’s Member Forum on Facebook.
Novice nurse practitioners can then compare practices and reflect on their own personal
capabilities.
Complex patients. Novice nurse practitioners in primary care who predominantly care
for complex and/or high-needs patients may find that these complex visits necessarily require
more time to explore issues in more depth and breadth with patients. In addition to time
pressures, novice nurse practitioners may feel more stress and fatigue from the increased
intensity and frequency of interactions with complex or high-needs patients. Thus, novice nurse
practitioners may require more support from colleagues and may need to be very mindful in
taking measures to maintain psychological fitness to practice. Actions for valuing and affirming
exchanges and patient engagement and reciprocity take more time with complex patients, but are
necessary for developing and maintaining therapeutic relationships and improving health
outcomes.
Recommendations. Developing and maintaining therapeutic relationships with complex
patients requires novice nurse practitioners to engage in daily self-reflection as part of
maintaining psychological fitness to practice. Novice nurse practitioners can practice the actions
under knowledge and competence, valuing and affirming exchanges, patient engagement and

55
reciprocity, and appreciating context consistently across all types of visits. Flemmer et al.’s
(2014) model of empathetic partnership for primary care was designed with marginalized or
more complex patients in mind, and the six key elements of Flemmer et al.’s model (reflection,
environment, language, knowledge, and partnership and empathy) incorporate all the themes for
actions that nurse practitioners can take to develop and maintain therapeutic relationships with
patients in primary care. Thus, this model is recommended for nurse practitioners working with
complex patients in primary care. If Flemmer et al.’s model were used in practice, it would need
to be taken up by the practice team as a whole, so as to provide consistency of approach, and
equivalent potential for therapeutic relationships between providers and patients. Additionally, a
team approach for complex patients may be beneficial for a number of reasons, including better
support for novice nurse practitioners. Working in a team may help to prevent psychological
distress or burnout over time, and may be more beneficial for nurse practitioners and patients,
opposed to independent practice settings.
Care transitions. A potential disruption in the consistency of care between nurse
practitioners and patients in primary care occurs when patients become hospitalized or transition
to other care settings (such as moving to a long-term care facility or community mental health
facility, becoming home-bound, or requiring referral to another provider for something outside
of the nurse practitioner’s scope of practice). Since patients value continuity in primary care–or
at least providers who are knowledgeable about their problems and history–and this continuity is
associated with improved provider-patient communication, it is important to consider how to
maintain therapeutic relationships during transitions in care. In this situation, the nurse
practitioner may not be able to provide the expertise to manage the patient’s current condition
and there may be a sense of loss of partnership and reciprocity between patients and their
primary care providers. Furthermore, a major health crisis, such as one that requires

56
hospitalization, would likely make patients feel more vulnerable, partly due to a loss of provider
continuity. However, there are actions novice nurse practitioners can enact in order to maintain
therapeutic relationships with patients who transition to other care settings.
Recommendations. Nurse practitioners need to address transitions in care and prepare
their patients in advance. In regards to hospitalization, novice nurse practitioners can advise their
patients about this limit on practice, advise patients how providers are notified about
hospitalizations and how they are able to remain updated on their condition (e.g., through
electronic records), and reassure patients that the nurse practitioner (or perhaps another colleague
from the same practice) will still visit them while they are in hospital (if this is possible,
depending on the location of hospital within a reasonable distance) or will speak with hospital
care providers (as needed) to receive updates as to the patient’s progress and expected discharge
date. Information should also be given about how (or whether) ongoing care from the nurse
practitioner will be provided during other transitions in care (as applicable), such as patient
movement to a long-term care facility, community mental health facility, or becoming homebound. When patients are referred to other care teams (e.g., private counseling, or home care
nursing), novice nurse practitioners can discuss with patients how the teams work together to
meet patients’ goals. In addition, novice nurse practitioners should create a clear care plan to
address how care will be provided when it is outside of the nurse practitioner’s scope (e.g.,
collaboration with another physician in a shared practice, or referral outside of primary care).
Having this care plan established in advance would help patients to feel that their needs will be
met and that they are comprehensively cared for by the nurse practitioner.
Summary. The new role and identity of novice nurse practitioners and new role in
primary care comes with changes to occupational and professional responsibilities, and
organizational and institutional alignments, thus changing how the proposed actions may be

57
enacted. In consideration of the challenges for novice nurse practitioners, the findings and
proposed actions have many implications for practice. Competence (or perceived competence)
may be affected by role identity. Enacting solidarity and problems with role ambiguity can
potentially worsen interprofessional relationships, decreasing support for novice nurse
practitioners and generally making it more difficult for novice nurse practitioners to develop and
apply their newfound knowledge and competence. Assigned patient panels with expectations for
high numbers of patient visits may lead to difficulties with patient engagement, reciprocity, and
some actions for valuing and affirming exchanges. Complex patients may require more time and
energy of novice nurse practitioners. Transitions in care present challenges for developing and
maintaining therapeutic relationships. The actions identified for developing and maintaining
therapeutic relationships can address some of the challenges identified by the implications for
practice. The other recommendations for addressing the implications and challenges can better
enable novice nurse practitioners to take action to develop and maintain therapeutic relationships
with patients in primary care.
Recommendations for Research
Unfortunately, there was no literature found that directly studied the therapeutic
relationships between nurse practitioners and patients in primary care. This may be due in part to
the associated difficulty in designing high-quality studies that would not be challenged by too
many interfering factors. Considering that therapeutic relationships underlie every interaction
with patients, the lack of research may also be due to the difficulty in separating the components
of the therapeutic relationship from the other more objective elements of providing primary care.
As a result, this literature review has generated implications for research. Due to the lack of
consensus on the relational processes, provider competencies, and relational outcomes of
therapeutic relationships in primary care, a concept analysis may be helpful. Due to the lack of

58
nurse practitioner-specific information regarding developing and maintaining therapeutic
relationships, it may be beneficial to research and develop models for therapeutic relationships
between nurse practitioners and patients in primary care. Due to the implications for nurse
practitioners in primary care who work predominantly with complex patients, it may be
beneficial to research how relationships between primary care providers and complex patients
may be different than relationships with patients who have simpler health care issues, and how
therapeutic relationships with complex patients can be best maintained over long periods of time.
Due to the number of implications and recommendations related to practice environment, future
research should also focus on how practice environment affects nurse practitioners’ (and other
primary care providers’) ability to develop and maintain therapeutic relationships.
Limitations
There are several considerations that limit the strength of the recommendations made in
this literature review. The conceptual consistency of components discussed in each of the studies
is unknown. For example, Kleiman’s (2014) concepts of connection, concern, respect, and
reciprocity were thought to be similar concepts to Bentley et al.’s (2016) concepts of affirming
exchanges and patient engagement. While a glossary of terms may provide some clarification, I
found this to be of little value, as many of these concepts were not defined in the studies
themselves. When the authors used terms like “patient-centered” to describe findings, the
descriptions of those terms provided in the studies were used instead. This allowed for greater
precision in the meaning of the concept in the study, comparing and contrasting concepts
between findings, and uncovering conceptual consistency. Still, conceptual consistency from
study to study cannot be confirmed with exact certainty.
This literature review did not aim to examine the impact of patient and provider factors
on therapeutic relationships, such as age, gender, ethnicity and culture. As stated in the

59
background, these factors cannot be controlled by nurse practitioners in practice. Although it is
difficult to make inferences into the effects that these factors had on the results of the studies
presented, the presence and effect of specific cultural beliefs in the participating patients cannot
be eliminated. However, factors such as these are not alterable, and controlling for such factors is
likely of little value to most general practices that roster a variety of patients from different age
groups, genders, ethnicities, and cultures.
The geographic location of the studies may have some affect on how nurse practitioners
are perceived by patients and other providers. Based on the political, environmental, and
professional climate, challenges and facilitators to nurse practitioner-patient interactions also
vary from location to location. Thus, application of this literature review’s findings may be
limited in areas where nurse practitioners are well established and well integrated into the
regional (or national) health care system. While the focus of this literature review was on the
context of practice in British Columbia, the findings of this review could still be applied to other
locations that are experiencing similar challenges that may be related to the newness of the nurse
practitioner role.
Summary and Conclusion
The results of this literature review have answered the question of what actions novice
nurse practitioners can take to help develop and maintain therapeutic relationships in primary
care. The findings can also be used to describe more specific actions that novice nurse
practitioners can take to meet the College of Registered Nurses of British Columbia’s entry-level
competencies for nurse practitioners (CRNBC, 2010). Based on the identified implications of
these actions for novice nurse practitioners in British Columbia, several recommendations for
clinical practice have been made. Challenges for novice nurse practitioners include role identity,
role clarity, quality of interprofessional relationships, and extrinsic obstacles (e.g., patient

60
empanelment, credentialing and privileges, and funding models). These challenges can be
addressed or reduced by adopting the recommendations for clinical practice. In addition, this
literature review provides recommendations for future research to address the gaps in knowledge
regarding the concept of therapeutic relationships in primary care, models for therapeutic
relationships, therapeutic relationships with complex patients, and the effects of practice
challenges on therapeutic relationships.
Perhaps it was Greenhalgh and Heath (2010) who best captured the essential challenge in
examining how practitioners can improve their therapeutic relationships: “the therapeutic
relationship is a complex, intersubjective and dynamic phenomenon that cannot be fully captured
objectively or reduced to a set of competencies or behaviours.” (p. 31). The identified actions are
not intended to be used as a checklist for practice. Instead, the identified actions must be
considered within the individual, organizational, social, environmental and political contexts of
practice. Despite this complexity, there is great value in the study of therapeutic relationships.
This literature review has identified that practicing as a nurse practitioner in primary care is
largely about therapeutic use of the nursing self in the context of providing medical care, while
navigating the context and challenges of advanced practice. This literature review is a valuable
to contribution to practice because nurse practitioners in primary care, from novice to
experienced practitioners, have to make complex, context-bound judgments about how to
approach consultations with patients, and all while navigating difficult times throughout the
therapeutic relationship. This literature review can prompt self-reflection and awareness, and
foster advancement by helping novice nurse practitioners to enact and further develop their
practice through consideration of the actions identified in this literature review.

61
References
Ainsworth-Vaughn, N. (1998). Claiming power in doctor-patient talk. Oxford, England: Oxford
University Press.
Auditor General of British Columbia. (2017). Physician funding models. Retrieved from
http://www.bcauditor.com
Bentley, M., Stirling, C., Robinson, A., & Minstrell, M. (2016). The nurse practitioner-client
therapeutic encounter: An integrative review of interaction in aged and primary care settings.
Journal of Advanced Nursing, 72(9), 1991-2002. doi:10.1111/jan.12929
Berry, S., Bloch, J., Goldenthal, H., Higgins, S., Hoath, L., Mattar, P…. Westamacott, G.
(Producers). (2017, May 03). Government has to stop looking for cheap way to address
doctor shortage, says GP [Audio podcast]. Retrieved from
http://www.cbc.ca/radio/thecurrent/
Brown, M. A., & Olshansky, E. F. (1997). From limbo to legitimacy: A theoretical model of the
transition to the primary care nurse practitioner role. Nursing Research, 46(1), 46-51.
Burge, F., Haggerty, J. L., Pineault, R., Beaulieu, M., Lévesque, J., Beaulieu, C., & Santor, D. A.
(2011). Relational continuity from the patient perspective: Comparison of primary healthcare
evaluation instruments. Healthcare Policy, 7(Special Issue), 124-138.
Byrne, P., & Long, B. (1976). Doctors talking to patients: A study of verbal behaviors of doctors
in the consultation. London, England: Her Majesty’s Stationery Office.
Canadian Institute for Health Information. (2015). Regulated nurses, 2014: RN/NP data tables.
Retrieved from https://www.cihi.ca/en
Canadian Institute for Health Information. (2016). Supply, distribution and migration of
physicians in Canada, 2015: Data tables. Retrieved from https://www.cihi.ca/en/physicians
Canadian Nurses Association. (2008). Code of ethics for registered nurses. Ottawa, ON: Author.
Retrieved from https://www.cna-aiic.ca
Canadian Nurses Association. (2010). Canadian nurse practitioner: Core competency
framework. Ottawa, ON: Author. Retrieved from https://www.cna-aiic.ca
Charlton, C. R., Dearing, K. S., Berry, J. A., & Johnson, M. J. (2008). Nurse practitioners’
communication styles and their impact on patient outcomes: An integrated literature review.
Journal of the American Academy of Nurse Practitioners, 20(7), 382-388.
doi:10.1111/j.1745-7599.2008.00336.x
College of Family Physicians of Canada. (2012). Best advice: Patient rostering in family
practice. Retrieved from: http://www.cfpc.ca

62

College of Family Physicians of Canada. (2016). Four principles of family medicine. Retrieved
from http://www.cfpc.ca
College of Registered Nurses of British Columbia. (2010). Competencies required for nurse
practitioners in British Columbia (Pub. No. 416). Vancouver, BC: Author. Retrieved from
https://www.crnbc.ca/
College of Registered Nurses of British Columbia. (2013). Boundaries in the nurse-client
relationship (Pub. No. 432). Retrieved from https://crnbc.ca
College of Registered Nurses of British Columbia. (2017). Nurse practitioners. Retrieved from
https://www.crnbc.ca/
Critical Appraisal Skills Programme. (2013). CASP checklists. Retrieved from http://www.caspuk.net
Defibaugh, S. (2014). Solidarity and alignment in nurse practitioner-patient interactions.
Discourse & Communication, 8(3), 260-277. doi:10.1177/1750481314537573
Defibaugh, S. (2015). Identity construction in nurse practitioner-patient interactions (Doctoral
dissertation). Retrieved from https://www.ideals.illinois.edu
Donabedian, A. (1966). Evaluating the quality of medical care. The Milbank Quarterly, 83(4),
691-729.
Faraz, A. (2016). Novice nurse practitioner workforce transition into primary care: A literature
review. Western Journal of Nursing Research, 38(1), 1531-1545.
doi: 10.1177/0193945916649587
Flemmer, N., Dekker, L, & Doutrich, D. (2014). Empathetic partnership: An interdisciplinary
framework for primary care practice. The Journal for Nurse Practitioners, 10(8), 545-551.
Grainger, K. (2004). Verbal play on the hospital ward: Solidarity or power? Multilingua, 23(12), 39-59.
Greenfield, S., Kaplan, S. H., Ware, J. E., Jr., Yano, E. M., & Frank, H. J. (1988). Patients’
participation in medical care: Effects on blood sugar control and quality of life in diabetes.
Journal of General Internal Medicine, 3(5), 448-457.
Greenhalgh, T., & Heath, I. (2010). Measuring quality in the therapeutic relationship. Retrieved
from: http://www.kingsfund.org.uk
Griffin, S. J., Kinmonth, A. L., Veltman, M. W., Gillard, S., Grant, J., & Stewart, M. (2004).
Effect on health-related outcomes of interventions to alter the interaction between patients
and practitioners: A systematic review of trials. Annals of Family Medicine, 2(6), 595-608.

63
Heath, C. (1992). The delivery and reception of diagnosis and assessment in the general practice
consultation. In P. Drew & J. Heritage (Eds.), Talk at work: Interaction in institutional
settings. Cambridge: Cambridge University Press.
Heritage, J., & Clayman, S. (2010). Talk in action: Interactions, identities, and institutions.
Oxford, England: Wiley-Blackwell.
Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C. G., & Gonnella, J. S.
(2011). Physicians’ empathy and clinical outcomes for diabetic patients. Academic Medicine,
86(3), 359-364. doi:10.1097/ACM.0b013e3182086fe1.
House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science,
241(4865), 540-545.
Johnson, R. (1993). Nurse practitioner-patient discourse: Uncovering the voice of nursing in
primary care practice. Scholarly Inquiry for Nursing Practice: An International Journal, 7(3),
143-163.
Kaplan, S. H., Greenfield, S., & Ware, J. E. (1989). Assessing the effects of physician-patient
interactions on the outcomes of chronic disease. Medical Care, 27(3 Suppl), S110-S127.
Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014). The influence of
the patient-clinician relationship on healthcare outcomes: A systematic review and metaanalysis of randomized controlled trials. PLoS ONE, 9(4), e94207. doi:
info:doi/10.1371/journal.pone.0101191
Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patientcentred care? A narrative review and synthesis of the literature from health policy, medicine
and nursing. Journal of Advanced Nursing 69(1), 4-15. doi:10.1111/j.13652648.2012.06064.x.
Kleiman, S. (2004). What is the nature of nurse practitioners’ lived experiences with patients?
Journal of the American Academy of Nurse Practitioners, 16(6), 263-269.
Koeniger-Donohue, R. (2007). Nurse practitioner-client interaction as resource exchange: The
nurse’s view (NP-client interaction). Journal of Clinical Nursing, 16(6), 1050-1060.
Krumholz, H. M, Butler, J., Miller, J., Vaccarino, V., Williams, C. S., Mendes de Leon, C. F., …
Berkman, L. F. (1998). Prognostic importance of emotional support for elderly patients
hospitalized with heart failure. Circulation, 97(10), 958-964. doi:10.1161/01.CIR.97.10.958
Kuhl, D. (2013). Relationships and healing: What we know cures; who we are heals. Workshop
presented at the College of Physicians and Surgeons of British Columbia Education Day and
Annual General Meeting 2013, Vancouver BC. Retrieved from https://www.cpsbc.ca

64
Laberge, M., Pang, J., Walker, K., Wong, S., Hogg, W., & Wodchis, W. P. (2014).
QUALICOPC (Quality and costs of primary care) Canada: A focus on the aspects of primary
care most highly rated by current patients of primary care practices. Retrieved from
http://www.cfhi-fcass.ca
Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C.
Norcross & M. R. Goldstein (Eds.), Handbook of psychotherapy integration (2nd ed., pp. 94129). New York, New York: Basic Books.
Levenstein, J. M., McCracken, E. C., McWhinney, I. R., Stewart, M. A., & Brown, J. B. (1986).
The patient-centred clinical method. 1. A model for the doctor–patient interaction in family
medicine. Family Practice, 3(1), 24–30.
Li, H., Koehn, C., Desroches, N., Yum, Y., & Deagle, G. (2007). Asymmetrical talk between
physicians and patients: A quantitative discourse analysis. Canadian Journal of
Communication, 32(3), 417-433.
Miller, W. L., Crabtree, B. F., Nutting, P. A., Stange, K. C., & Jaén, C. R. (2010). Primary care
practice development: A relationship-centered approach. Annals of Family Medicine, 8(Suppl
1), s68-s79. doi:10.1370/afm.1089.
Mohammadi, E., Abedi, H. A., Jalali, F., Gofranipour, F., & Kazemnejad, A. (2006). Evaluation
of ‘partnership care model’ in the control of hypertension. International Journal of Nursing
Practice, 12(3), 153-159.
Mumford, E., Schlesinger, H. J., & Glass, G. V. (1982). The effect of psychological intervention
on recovery from surgery and heart attacks: An analysis of the literature. American Journal of
Public Health, 72(2), 141-151.
Osler, W. (1892). Principles and Practice of Medicine. New York, New York: Appleton.
Peden, A., Staal, J., Rittman, M., & Gullett, D. (2015). Nurse-patient relationship theories:
Hildegard Peplau, Joyce Travelbee, and Ida Jean Orlando. In M. Smith, & M. Parker (Eds.),
Nursing theories and nursing practice (4th ed., pp. 67-86). Philadelphia, PA: F. A. Davis
Company.
Peplau, H. (1992). Interpersonal relations: A theoretical framework for application in nursing
practice. Nursing Science Quarterly, 5(1), 13–18.
Peplau, H. (1997). Peplau’s theory of interpersonal relations. Nursing Science Quarterly, 10(4),
162-167.
Prodan-Bhalla, N., & Scott, L. (2016). Primary care transformation in British Columbia: A new
model to integrate nurse practitioners. Retrieved from: http://www. http://bcnpa.org
Registered Nurses Association of Ontario. (2012). Establishing therapeutic relationships.
Retrieved from http://www.rnao.org

65

Robinson, J. D., Tate, A., & Heritage, J. (2016). Agenda-setting revisited: When and how to
primary-care physicians solicity patients’ additional concerns? Patient Education &
Counseling, 99(5), 718-723.
Sangster-Gormley, E., & Canitz, B. (2015). A survey of nurse practitioner practice patterns in
British Columbia. January 2014. Victoria, BC: University of Victoria.
Sheridan, N. F., Kenealy, T. W., Kidd, J. D., Schmidt-Busby, J. L., Hand, J. E., Raphael, D. L.,
… Rea, H. H. (2012). Patients’ engagement in primary care: Powerlessness and compounding
jeopardy. A qualitative study. Health Expectations, 18(1), 32-43. doi:10.1111/hex.12006
Silverman, B. D. (2012). Physician behavior and bedside manners: The influence of William
Osler and The Johns Hopkins School of Medicine. Proceedings of Baylor University Medical
Center, 25(1), 58-61.
Squier, R. W. (1990). A model of empathic understanding and adherence to treatment regimens
in practitioner-patient relationships. Social Science Medicine, 30(3), 325-339.
Stivers, T. (2007). Prescribing under pressure: Parent-physician conversations and antibiotics.
New York: Oxford University Press.
Street, R. L., Jr., & Voigt, B. (1997). Patient participation in deciding breast cancer treatment
and subsequent quality of life. Medical Decision Making, 17(3), 298-306.
Sullivan-Bentz, M., Humbert, J., Cragg, B., Legault, F., Laflamme, C., Bailey, P. H., &
Doucette, S. (2010). Supporting primary health care nurse practitioners’ transition to practice.
Canadian Family Physician, 56(11), 1176-1182.
Ward, M. M., Sundaramurthy, S., Lotstein, D., Bush, T. M., Neuwelt, C. M., & Street, R. L.
(2003) Participatory patient-physician communication and morbidity in patients with systemic
lupus erythematosus. Arthritis Care and Research, 49(6), 810-818.
Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of
Advanced Nursing, 52(5), 546-553.
Wiechula, R., Conroy, T., Kitson, A. L., Marshall, R. J., Whitaker, N., & Rasmussen, P. (2015).
Umbrella review of the evidence: What factors influence the caring relationship between a
nurse and patient? Journal of Advanced Nursing, 72(4), 723-734. doi:10.1111/jan.12862
Williams, A., & Jones, M. (2006). Patients’ assessments of consulting a nurse practitioner: The
time factor. Journal of Advanced Nursing, 53(2), 188-195.

66
Appendix A
Literature Review Matrix
Article/Study
Design/ Overview
Bentley et al. (2016)
Integrative review
using Whittemore
and Knafl’s
methodology.
To review key
features of NP-ct
interaction in
therapeutic encounter
to inform the
development of NPled memory clinics.
Focus on care of
older people in
community and
facilities. Included
primary care settings.
Authors are research
fellows or professors
in health sciences
and nursing, all from
Australia.

Strengths &
Limitations
- 10 studies included,
representing >900 NPs
and their cts.
- qualitative,
quantitative, mixed
methods
- search methods and
search terms welldescribed
- quality of papers
included were assessed
using certain criteria;
all studies assessed as
moderate in quality
- data abstraction and
synthesis described
- studies included in
the review were from
the US and UK
- detailed analysis of
individual articles

Important Findings

Utility

- 3 key factors of NP-ct
interation: NP expertise &
influence of context (clinic
setting, visit purpose); affirming
exchange; high levels of ct
engagement.
- affirming communication=
positive regard, respect, trust,
openness, asking for more
information about ct’s
lives/condition
- affirming exchange= giving
emotional support of
encouragement20154
- social and emotional aspects of
pt’s lives discussed when the
context of the encounter
required it- e.g. concerns with
acceptability/cost of treatments
- high pt satisfaction tied to
style of communication
(biopsychosocial engagement
provides affirming exchange)
and time spent with ct
- with this approach, cts are
more engaged, more satisfied,
and more likely to adhere to tx
plans
- to understand each episode of
care as a therapeutic encounter

- the therapeutic encounter is
where the therapeutic
relationship is developed and
maintained, thus answers
questions about features of
these encounters that have
positive results with patients,
thus may contribute to
maintain therapeutic
relationships
- noted that different contexts
created different types of
therapeutic encounterimplications for primary care
setting where patients present
in different contexts over a
long period of time- does
increased breadth of contexts
of visits in primary care
contribute to therapeutic
relationships?
- review included articles that
studied the PC setting and
studied NPs, thus very
applicable

67
Article/Study Design/
Overview
Defibaugh (2014)
Ethnographic research
study discussing how
solidarity is negotiated in
interactions during
medical visits between
NPs and pts.
Sample was one female
NP working as diabetes
specialist on internal
medicine team in hospital,
plus 20 of her patients
(13F, 7M, age 28-82).
Data collected over 2
month period July-Aug
2012. Included pre and
post interviews with NP,
audio-recordings of
medical visits, and written
survey for patients.
Focus on NP in inpatient
setting (not primary care)
Author is philosophy
major from U of Illinois
US

Strengths &
Limitations
- used multitheoretical approach:
transcribed
recordings of medical
visits, observational
data, and interviews
- used conversation
analysis as analytical
framework
- does not explain
how the NP was
chosen
- data based on only
one NP’s
consultations
- need to consider
other contextual
factors to fully
understand the
influence of solidarity
and alignment, and
the author does
mention tehis

Important Findings

Utility

- NP decreases social distance
between self and pt, allows pt
to share power, and allows pt to
identify as self outside of pt
identity. This creates solidarity
btw NP and pt.
- NP does this by using small
talk, saying “we” or “our” (1st
person plural pronouns)when
discussing tx options and
decision-making (this creates a
sense of shared ownership,
shared role of experiencer, and
shared decision maker),
encouraging pt to speak/share
narratives, and being interested
in their non-pt identity
- pt’s also use “we” in similar
ways
- NP doesn’t interrupt, enacts
supportive moves (e.g. yes,
okay, good, aren’t you glad you
mentioned it)
- reasons for solidarity may be
the middle space position of the
NP in the medical
hierarchy/pt’s eyes/NP’s eyes
- the NP said she worked more
on the relationship with the pt
because she perceived that pts
would not tolerate any negative
interaction with her whereas
they would tolerate more from
the attending physician; feels
pts will ask her to leave but
wouldn’t for the MD
- in this way, gaining solidarity
with the pt may provide the NP
with more perceived power

- discusses new conceptssolidarity and alignmentin the therapeutic
relationship that are only
hinted at in other articles,
but clearly have influence
on aspects of the
therapeutic relationship
described by other authors
– although the NP’s
relationship in hospital
context is short-term,
solidarity and alignment
certainly would have
effects in longitudinal
context, building
relationship over time
- not a primary care
setting, so there is the
impact of the inpt context
and the power imbalance
within the hospital context
(pt taken out of
community/ normal
environment= more
vulnerable)
- types of interactions- e.g.
discussing new diagnosis,
changing medications- are
similar to what is done in
primary care (e.g., the NP
in this setting wasn’t
performing specialized
hospital procedures)

68
Article/Study Design/
Overview
Defibaugh (2015)
Doctoral dissertation
based on an
ethnographic study
exploring identity
construction in NP-pt
interactions as it occurs
through specific
linguistic moves and
stylistic choices.
Sample was 48 medical
visits with 5 different
NPs. Data from
audiorecordings of visits
and interviews with
providers and pts. Uses
Agha’s theory of figures
of personhood.
Patients aged 28-82, 13F
7M
Focus is on inpatient and
outpatient visits: 1
inpatient diabetes
specialist NP (20 visits
with pts), 4 outpatient
NPs at community clinic
(3 at men’s health
primary care clinic and
one from cardiac clinic;
total 28 visits with pts).
Location Midwest US.
Used audiorecordings
and post-visit interviews
with pts and NPs. 2phase data collection
(the inpt NP was used in
Defibaugh’s previous
work).
Author is philosophy
major from U of Illinois
US

Strengths &
Limitations
- Ethnographic
discourse analytic
methodology
- uses both emic and
etic viewpoints
- very detailed,
thorough description
of data collection and
analysis
- all female NPs used

Important Findings

Utility

- NPs are able to balance both
instrumental and interactional goals
to construct the ID of “caring and
competent” provider, using a ptcentered approach
- NPs align with caring provider ID
using linguistic moves of solidarity
(e.g. using small talk, inclusive 1st
person pronouns, hedging and
indirect speech)
- NPs align with competent
provider ID by attending to their
occupational and professional
responsibilities, recognizing
responsibility to pts, and creating
alignments to organizations and
prof institutions. Also share
knowledge and use singular 1st
person pronouns, use of “I” and
institutional “we”, to highlight
medical competency
- use of “I” as experienced authority
figure
- use lay terms and translate health
information, providing “epistemic
access” to medical info for the pt
- follow medical checklist but allow
topic to deviate based on pt
responses; direct attention to what
NP feels is important but still
address pt concerns
- balance of interpersonal (using
caring ID) and instrumental goals
(using competent ID)
- Pts align with different IDsdeferent pt (older, not sanctioned by
NPs), good pt, pt-consumer
-“small talk can be seen as one way
in which providers are able to build
long-term relationships with
patients through a focus on
interpersonal rather than
instrumental goals” (p. 62)
- dual responsibility with use
of“we” in different ways- including
pt in NP actions, including self in pt
actions (sometimes pts do this too)
- use of “we” encourages shared
connection and responsibility, sense
of devotion

- expands on earlier
2014 article which
discussed techniques,
but explains in more
detail how pts and NPs
view the NP as caring
and competent and that
this balance is what
gives pts satisfaction
- references the
relevance of findings to
developing long-term
relationships with pts,
as those seen in primary
care
- unlike previous 2014
article, this is based
mostly on NPs in
primary care role (4/5
NPs in primary care)
- findings align with
caring themes in other
articles

69
Article/Study Design/
Overview
Defibaugh (2015)

Strengths &
Limitations

Flemmer et al. (2014)

- uses WSWs as an
example of a
marginalized
population; this focus
on marginalized
patients is relevant to
the patient rosters of
many NPs in BC
- framework can be
used for all pts, not
just marginalized pts
- framework
influenced by New
Zealand nursing’s
cultural safety- ?
applicability to BC
- has not been tested
in practice- no
original research to
support the
framework, though
the key elements of
the framework were
developed from other
research

Presentation of
framework, to create
effective and therapeutic
partnerships with
patients.
Authors are a FNP,
educator, and CNS, all
from New Zealand.
No patient dataexemplar for women
who have sex with
women/ used theories
relevant to vulnerable or
marginalized patients

Important Findings

Utility

- indirect speech, including use of
mitigated and justified advice, for
medical directives allows for shared
decision-making, decreases
imposition on pt, thus creates
rapport, improved relationships.
- NPs prioritize rapport and
relationship building
- pt’s co-construct competent
provider by confirming info told to
them by others
- pts were very satisfied and rated
these NPs highly
- pts also construct their own
identities: deferent pt, good pt,
knowledgeable but non-compliant
pt, and non-pt (often shifting, rather
than static IDs)
- pts may be willing to share more
about themselves (non-pt ID)
personally due to the “middle
spacing” of the NP/ NP not as
powerful/distant as MD
- Empathetic Partnership comprises
6 elements: reflection, environment,
language, knowledge, partnership,
and empathy
- reflection: reflect on own biases,
cultures, power, privilege; question
roles, assumptions, filters,
perceptions. ongoing process.
- environment: physical- art and
information, nondiscrimination
policy posted
- language- reveals assumptions;
nuanced language
- knowledge- for diverse
populations; individual pt within
statistical population
- partnership & empathy- shift
power to partnership focus. Pt is the
expert on themselves. NP is able to
understand the pt’s feelings and
world view, be nonjudgmental, and
communicate that understanding.

- the framework is
supposed to help
practitioners create
effective and
therapeutic partnerships
with patients
- the framework seems
to have particular
relevance to
maintaining therapeutic
relationships in the
context of increased
patient vulnerabilitythat is, vulnerability of
the marginalized patient
- is intended for and
informed by primary
care nurse practitioners

70
Article/Study Design/
Overview
Kleiman (2004)
Qualitative study with
interviews of 6 NPs.
To explore the lived
experience and meaning
of NPs interactions with
patients, and create a
structure to articulate.
Specialties and work
settings for the NPs were:
psychiatric NP in
community mental health,
adult NP at cardiac unit in
hospital, FNP in college
student health center,
geriatric NP in LTC
facility, adult NP in
urology private practice,
and pediatric NP in
partnership with a
physician.
No patients
Author is a PhD
psychiatric NP in New
York, U.S.

Strengths & Limitations

Important Findings

Utility

- used systematic criteria
to evaluate the described
experiences
- small sample size, but
appropriate for a
phenomenological study
- all female NPs- did not
include male NPs- are
their experiences different
than female NPs?

- meanings: openness,
connection, concern (for
pt and self), respect,
reciprocity, competence,
time, and professional
identify
- focus on relationship
between the patient and
NP and the
meanings/understandings
that stem from this
relationship that are not
necessarily related to
outcomes of health-related
interventions
- relationship-oriented not
disease-oriented
- “connection flourishes in
an ongoing reciprocal
process of collaborative
engagement of the
patient’s health-related
concerns.”
- despite time concerns,
interactions are unhurried,
open and attentive
- intimate and ongoing
relationship

- emphasizes the
importance of establishing
and maintaining
relationships with patients
- considers the NP’s
perspective, which differs
from most of the other
articles that focus on
patient’s perspectives,
observational studies, or
presenting frameworks
- included the perspective
of a FNP
- some primary care but
population-focused
primary care.

71
Article/Study Design/
Overview
Koeniger-Donohue (2006)
Qualitative observational
study with 2 expert NP
participants and 8 client
participants.
Aim to explore NP client
encounters from the
nurse’s perspective using
a resource exchange
paradigm. Focus on what
resources NPs anticipate
they will provide to their
clients before a visit, the
resources that are actually
provided and the NPs
perception of what
transpired after the visit.
Focus on NPs working in
women’s health.
Didn’t go into details
about pts- but all middle
aged females.
Author is a PhD APRN
and assistant professor in
the graduate program in
primary health care
nursing in Boston, U.S

Strengths & Limitations

Important Findings

Utility

- NP participants selected
purposely for their
excellent reputations
- studied beginning,
evolving, and established
relationships between NPs
and their pts
- examined findings using
Foa and Foa’s resource
exchange theory as a
framework, but did not
limit their interpretation
when findings did not fit
within Foa and Foa’s
classes of resources
- only female NPs

- saw 5/6 of Foa and Foa’s
Resource Exchange
Theory classes of
resources: (a)‘services’
(activities that affect the
body and include labour
for another); (b)
‘information’ (advice,
opinions, instruction); (c)
‘goods’ (tangible
products; (d) ‘love’ (an
expression of affectionate
regard, warmth, or
comfort); (e) ‘status’ (an
evaluative judgment that
conveys prestige, regard,
or esteem). Did not see (f)
‘money’ (currency or a
standard unit of
exchange).

- exchange theory=
resources expected and
received which contribute
to and build the exchange
relationship

*Note: “Resource
exchange is defined as any
situation where two people
interact voluntarily
(providing each other with
activities in a reciprocal
arrangement),
communicate freely and
derive some mutual
benefit from the
interaction” (p. 1052/Foa
& Foa 1974, 1976).
Exchange theorists have
found that the nature of
interpersonal exchange
processes can be
understood by examining
what resources are
involved in a reciprocal
context (Foa 1971, Foa et
al. 1972, Foa & Foa 1974,
Turner 1987)

- added a resource
category called
affirmation (reassurance,
reinforcement, support and
feedback)
- NPs more easily use the
full range of resources in
established relationships

- the focus of this article is
not necessarily on the
therapeutic relationship,
but has implications for
relationship developmentNPs may need to reflect
on how initial visits differ
from visits later in the
relationship, in terms of
the amount and type of
resources the NP provides
to clients over time.
- primary care, but
population focused on
women’s health

72
Article/Study Design/
Overview
Williams et al. (2006)
Qualitative study using 10
patient interviews based
on 1 NP’s consultations
with these patients. Part of
a wider case study.
Aim to explore patients’
views about consulting
with a primary care NP.
Focus on primary care.
Authors are
Based in the UK.

Strengths & Limitations

Important Findings

Utility

- in-depth patient
interviews occurred
immediately after the
consultation
- pts were aged 19-76, half
men half women
- breadth of exploration
sacrificed for depth of
analysis
- data coded and analyzed
by both investigators
- only based on 1 NPs
consultations, but it did
reflect the findings of
larger studies comparing
NPs to GPs in terms of
patient satisfaction
- only 1 female NP studied
- adds to qualitative data
that explains WHY pts are
satisfied with NP care

- all but one pt appreciated
the extra time given by the
NP (note: the one pt came
in for emergency chest
problem was the oldest at
age 76 and male; other pts
appeared to be visiting for
chronic conditions or
minor acute infections)
- pts appreciated
discussion of factors
affected by their
problem/symptoms, such
as family, work, and
relationships.
- pts appreciated time to
attend to complex
emotional needs
- pts appreciated style of
consulting, questioning,
and discussing of
treatment options other
than prescriptions

- time was also mentioned
in other articles, and
focusing on that one
element of time in this
article allows a better
explanation for why and
how (?if) that element can
be effectively used to
maintain therapeutic
relationships
- focused on primary care
setting exclusively
- focused on NPs
exclusively for the study,
though participants were
asked to compare to GP
care (but no specific GPs
were formally assessed by
the study)

73
Appendix B
Themes and Subthemes
THEMES
Sub-themes
Competency &
Knowledge
Reflection &
selfmanagement of
practitioner
Affirming
exchanges
Empathy/Recog
nizing emotions
Presence/mindf
ulness/
attentiveness
Patient
engagement/
Reciprocity
Patient
satisfaction
Consistency/
commitment
Context
Context of
encounter/
reason for visit
Health care
environment
Time spent by
practitioner

Bentley
et al.
(2016)
Yes

Defibaugh
(2014)

Defibaugh
(2015)

Indirect

Yes

Flemmer
et al.
(2014)
Yes

No

Yes

Yes

Yes

Yes

Yes

Kleiman
(2004)
Yes

KoenigerDonohue
(2006)
Yes

Williams
(2006)

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Indirect

Indirect

Yes

Indirect

Yes

Yes

Yes

Yes

Indirect

Indirect

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Indirect

Indirect

Yes

Yes

Indirect

Yes

Yes

Indirect

Yes

Indirect

Yes

Yes
Yes

Yes
Yes

Yes
Yes

Yes
No

No
No

Yes
Yes

Yes
Yes

No

Yes

Yes

Yes

No

No

No

Yes

Yes

Yes

No

Yes

Yes

Yes

Yes

Yes= explicitly mentioned by name/descriptor in the article
Indirectly= implicitly mentioned in the article through the description of patient interviews/data, or present but not
mentioned using the same name/descriptor
No= not mentioned explicitly or indirectly

74
Appendix C
Factors, Elements, Concepts, Resources, and Meanings by Article
Author
Bentley et
al. (2016)

Factors, Elements, Concepts, Resources, and Meanings
- show expertise/knowledge
- provide affirming exchanges by giving emotional support and encouragement
- positive regard, respect, trust, openness, empathy, reciprocity, and
concern/inquisitiveness into biopsychosocial aspects of patients’ lives/conditions
typify an affirming communication style
- consider the context/purpose of the visit

Defibaugh - decrease social distance between NP and patient by using small talk, and first(2014)
person pronouns (e.g. ‘we’ or ‘our’) when discussing treatment options and
engaging patient in decision-making (solidarity and reciprocity)
- do not interrupt narratives; show supportive moves instead such as saying ‘yes’,
‘okay’, and ‘good’
- explore patient’s identity outside of their patient identity
Defibaugh - balance instrumental and interactional goals in the patient consultation
(2015)
(competence/caring)
- align with caring provider identity and create solidarity with patient by using
small talk, inclusive first person pronouns, hedging, and indirect speech
- align with competent provider identity by attending to occupational and
professional responsibilities and create alignments to organizations and
institutions
- create comfortable communicational atmosphere by using lay terms, following
medical checklist but allowing topic to deviate based on patient’s responses
- engage patients by encouraging them to share their narratives, getting to know
them beyond their identity as patients, and involving them in decision-making
Flemmer - reflect on own biases, cultures, power and privilege
et al.
- question roles, assumptions, filters, and perceptions
(2014)
- display appropriate art and information to create cultural safety
- use of nondiscriminatory and nonjudgmental language with attention to
assumptions
- openness
- be empathic, encouraging
- sustain knowledge base for diverse populations and consider individual patient
within given statistical tendencies
- promotes partnership by communicating an understanding of the patient’s
feelings and worldview to the patient in a nonjudgmental way

75

Author
Kleiman
(2004)

Actions
- provide affirming exchanges by being attentive, available, open, welcoming,
authentic, and evocative
- show openness, concern, respect
- engage patients in care decisions, ensure there is patient exchange (not just onesided)
- consultations are unhurried despite time concerns
- self-reflection on own personal and professional capabilities and ability to
identify and act to meet patient needs

KoenigerDonohue
(2006)

- provide affirming exchanges by using reassurance, reinforcement, support, and
feedback
- engage patient in care decisions
- use services, information, goods, love, and status in interactions (i.e. balance
instrumental and interactional goals)
- use as much time as is needed to provide an in-depth, thorough consultation
- discuss factors affected by their problem (family, work, relationships)
- use questions, listen to patients and discuss treatment options other than
prescriptions
- engage patient in decision-making
- non-intimidating manner with patients

Williams
and Jones
(2006)

76
Appendix D
Summary of Implications and Recommendations
Implication
Professional
Identity

Solidarity

Role
Ambiguity

Recommendations
• Daily self-reflection.
• Support from colleagues/mentors/leaders.
• Incorporate actions into learning plan.
• Network with others via BCNPA/practice-based small group learning
programs/journal or case review groups for practice.
• The ‘we’ of solidarity should be extended not just to the nurse
practitioner-patient team, but also to the health care team as a whole
(e.g.
•
•
•
•
•

Patient
Empanelment

•
•
•

Complex
Patients

•
•
•

Care
Transitions

•
•

Self-reflection.
Discussion with colleagues.
Alignment to nurse practitioner practice leader for inter-disciplinary
education and awareness.
Partnership with BCNPA.
Self-education on funding models, and advocating with colleagues,
practice leaders, management, through surveys, and lobbying
government.
Look to research for evidence regarding fair caseloads for nurse
practitioners.
Discuss fair caseload with site manager/colleagues/employers.
Connect with colleagues through local community of practice and/or
BCNPA Member Forum on Facebook.
Daily self-reflection.
Team approach for complex patients.
Team use of Flemmer et al.’s Empathetic Partnership model for
Primary Care.
Prepare patients in advance of care transitions.
Advise patients, re: how provider remains updated, how teams work
together, and prepare patients for times when care may be outside nurse
practitioner scope.