Preventive Services: Role of the Nurse Practitioner

Purpose: To describe current practices of military nurse practitioners with regard to clinical preventitive services; develop a grounded theory that explicates factors that facilitate and inhibit the delivery of clinical
preventive services; describe the military consumer's experience of care given by nurse practitioners; and determine the essential features of a clinical preventive health care system within the military, the feasibility of initiative implementation, and the readiness of the system for implementation.

Design: Naturalistic inquiry, through applying multiple instances of triangulation within and across
methodologies in order to reveal a unique dimension embedded within the whole.

Sample: The entire population of military nurse practitioners (Air Force, Army, and Navy) in the
Department of Defense was invited to participate (N = 403) with 246 consenting participants (61%). Additionally, 32 patients/clients of a subset of 20 military nurse practitioners also consented to participate.

Instrumentation: Preventive Care Survey II (Ronan, 1996), procedures consistent with qualitative
methodologies for content analysis, grounded theory, and phenomenology.

Methods: A descriptive quantitative/qualitative survey designed was used in Phase I, Grounded
Theory in Phase II, Phenomenological approaches in Phase III, and triangulation methodologies in Phase IV.

Analysis: Quantitative and qualitative data analysis for Phase I were used to describe the clinical preventive services offered by military nurse practitioners as well as aspects of practice that detracted from and facilitated the ability to provide these services. In Phase II, data were used to develop a grounded theory that explicated the impact of social-structural and social-psychological processes in the delivery of clinical preventive services from the perspectives of military nurse practitioners. Interviews with patients/clients in Phase III were analyzed to capture a description of the essence of the care experience from the perspective of the military consumer through phenomenological approaches. In Phase IV data triangulation analysis, a comparative thematic matrix of the three previous data sets, was used to form a theoretical schema including the milieu of military health care and the presence of clinical preventive services, the role of the nurse practitioner within this system, and the process of military nurse ractitioner-client transactions within the health care experience.

Findings: On three domains of primary care prevention, assessment, counseling/treatment, and
preventive services, military nurse practitioners reported marginal improvement in the level of provided services contrasted with a reference group of national nurse practitioners five years earlier. When queried, most military nurse practitioners valued providing higher levels of services although these values fell short of the recommended levels indicated in Healthy People 2000. Reasons most identified as barriers were, clinician uncertainty, insufficient time with patients, and fragmentation of health care delivery. Behind the level of success with prevention activities was a salient desire for legitimacy seeking through extraordinary "niche filling" activities. These activities were necessary for successful "role identity" within a context of an inadequate infrastructure for disease prevention health promotion activities. From patients/clients perspectives, prevention was an invisible concept. Health care in the military is experienced as the development of interpersonal and systems relationships with others, grounded in personal commitment, efficiency of services and health/illness problem resolution, regardless of the professional role and title of the health care provider. From a systems point of view, here is evidence to suggest that an overarching strategic plan for integrated healthcare is lacking.

Final report is available on NTRL: https://ntrl.ntis.gov/NTRL/dashboard/searchResults/titleDetail/PB2005102...