Donna Frost

Nature of professional artistry 185 6 practice encounter. It illustrates how Margaret, an NP working in the GP clinic, was dealing with ‘parts’ while remaining open to the larger picture, alert to how the details in both her own and the patient’s story were contributing to the meaning of the whole encounter. A patient, Ms. C, not acutely unwell but with abdominal pain is seen by Margaret. Ms. C is very anxious, her blood sugars are unstable, she has had pain for some days and is worried that she has something serious. Margaret does not generally see patients with the primary presenting complaint of abdominal pain, but the practice is having a very busy day and she has agreed with the GP to see Ms. C, conduct her assessment and to return to discuss differential diagnoses and the next steps with him. While asking Ms. C questions about the location and nature of her pain, and whether she has had any difficulty with or pain by passing urine, Ms. C becomes irritated and says, frustrated, ‘Don’t you think I haven’t thought of that? Of course it’s not that.’ Margaret listens, nods and says, ‘I’m covering a lot of ground you’ve already been over yourself.’ She waits for the patient to respond (‘Yes, that’s right’) and then Margaret clarifies, briefly, the process of ruling things out in order to refine the clinical picture. She does not use the clinical standard to hide behind as she could have (“Sorry about these questions but I have to follow procedure”). Instead she uses the process to help Ms. C see that the problem is being taken seriously and that Margaret is being thorough and systematic. She asks Ms. C more explicitly what she has ruled out herself, how and why etc. She also changes tack a little with respect to her own focus, exploring now the reason for Ms. C’s anxiety and sense of urgency. Ms. C is taken seriously and becomes an active partner in the investigation; she speaks more freely, including about her own concerns. In turn Margaret has more relevant information available and, as well as building up a thorough clinical picture, invests in the relationship with Ms. C, particularly important in primary care. Dialoguing with parts and whole leads to a deeper understanding of both. Both background and foreground have meaning to the nurse practising with artistry and this is expressed in action when the nurse acts pertinently and particularly with understanding and attention for both parts and whole. I do have a lot of knowledge – clinical knowledge, theoretical knowledge. But I don’t “tell it”, usually. I use it, you know, I use it to puzzle things out. To place the particular details, to give me options. […] And I distil it for my patients. […] I follow their lead if at all possible. (LilianNPI-CRC- 20131104 -pp. 11 - 12 )