Telephone nurses' experience of problems with telephone advice in Sweden

Factors affecting communication during telephone triage in medical call centres: a mixed methods systematic review

BACKGROUND

Telephone triage is used to optimise patient flow in emergency primary healthcare. Poor communication can lead to misunderstandings and compromise patient safety. To improve quality, a comprehensive understanding of factors affecting communication in medical call centres in primary care is needed. The aim of this review was to identify such factors and to describe how they affect communication during telephone triage.

METHOD

A mixed-method systematic review was performed. In April 2021 and June 2023, MEDLINE, Embase, CINAHL, and Web of Science were searched for original studies describing communication during telephone triage in primary care medical call centres handling all types of medical problems from an unselected population. All studies were screened by two authors, blinded to each other's decisions. Disagreements were resolved by a third author. A framework was created by the thematic synthesis of the qualitative data and later used to synthesise the quantitative data. By using convergent integrated synthesis, the qualitative and quantitative findings were integrated. The Mixed Methods Appraisal Tool was used to assess methodological limitations.

RESULTS

Out of 5087 studies identified in the search, 62 studies were included, comprising 40 qualitative, 16 quantitative and six mixed-method studies. Thirteen factors were identified and organised into four main themes: organisational factors, factors related to the operator, factors related to the caller and factors in the interaction. Organisational factors included availability, working conditions and decision support systems. Factors related to the operator were knowledge and experience, personal qualities and communication strategies. Factors related to the caller were individual differences and the presented medical problem. Factors in the interaction were faceless communication, connection between operator and caller, third-person caller and communication barriers. The factors seem interrelated, with organisational factors affecting all parts of the conversation, and the operator's communication in particular.

CONCLUSION

Many factors affect the structure, content, and flow of the conversation. The operators influence the communication directly but rely on the organisation to create a working environment that facilitates good communication. The results are mainly supported by qualitative studies and further studies are needed to explore and substantiate the relevance and effect of individual factors.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022298022.

The design of an Obstetric Telephone Triage Guideline (OTTG): a mixed method study

BACKGROUND

Clarifying the dimensions and characteristics of obstetric telephone triage is important in improving the quality of services in the health system because researchers can evaluate the effectiveness of treatment, care and diagnostic measures in the form of obstetric telephone triage by developing a guideline. Therefore, this study aimed to design an Obstetric Telephone Triage Guideline (OTTG) using a mixed-method study.

METHODS

The present study was carried out using an exploratory sequential mixed method study in two qualitative and quantitative phases. An inductive-deductive approach was also used to determine the concept of obstetric telephone triage. In this respect, a qualitative study and a literature review were used in the inductive and deductive stages, respectively. Moreover, the validity of the developed guideline was confirmed based on experts' opinions and results of the AGREE II tool.

RESULTS

The guideline included the items for evaluating the severity of obstetric symptoms at five levels including "critical", "urgent", "less urgent", "no urgent", and "recommendations". The validity of the guideline was approved at 96%, 95%, 97%, 95%, 93%, and 100% for six dimensions of AGREE II including scope and purpose, stakeholder involvement, the rigor of development, clarity of presentation, applicability, and editorial independence, respectively.

CONCLUSION

The OTTG is a clinically comprehensive, easy-to-use, practical, and valid tool. This guideline is a standardized tool for evaluating the severity of symptoms and determining the urgency for obstetrics triage services. By using this integrated and uniform guideline, personal biases can be avoided, leading to improved performance and ensuring that patients are not overlooked. Additionally, the use of OTTG promotes independent decision-making and reduces errors in triage decision-making.

The telephone nursing dialogue process: an integrative review

BACKGROUND

Telephone nursing involves triage, advice, and care management provided by a nurse over the telephone. The telephone nursing dialogue process has been used clinically in telephone nursing in Sweden for several years to structure the communication and ensure a safe assessment and advice. Studies are needed to determine whether there is sufficient scientific evidence to support the method.

AIM

To describe the scientific basis of the phases of the telephone nursing dialogue process.

DESIGN

This was an integrative review.

METHODS

The literature searches were performed in August 2023, in the PubMed, CINAHL, Cochrane Database of Systematic Reviews and SwePUB databases. Sixty-two articles were included. Data was sorted deductively according to the five phases of the telephone nursing dialogue process and categorized inductively to form subcategories describing the content of each phase.

RESULT

All five phases in the telephone nursing dialogue process were supported by a range of articles (n = 32-50): Opening (n = 32), Listening (n = 45), Analysing (n = 50), Motivating (n = 48), and Ending (n = 35). During the opening of the call, the nurse presents herself, welcomes the caller and establishes a caring relationship. In the listening phase, the nurse invites the caller to tell their story, listens actively and confirms understanding. During the analyzing phase, the nurse gathers, assesses, and verifies information. In the motivating phase, the nurse reaches a final assessment, informs the caller, gives advice and creates a mutual agreement and understanding while supporting the caller. Ultimately, the nurse ends the call after checking for mutual agreement and understanding, giving safety-net advice, deciding on whether to keep monitoring the caller and rounding off the call.

CONCLUSION

The phases of the telephone nursing dialogue process as described in the scientific literature are well aligned with the theoretical descriptions of the telephone nursing dialogue process.

Video triage in calls concerning children with fever at an out-of-hours medical helpline: a prospective quality improvement study

BACKGROUND

Parents often contact out-of-hours services due to worry concerning febrile children, despite the children rarely being severely ill. As telephone triage of children is challenging, many children are referred to hospital assessment. This study investigated if video triage resulted in more children staying at home. Secondary aims included safety, acceptability and feasibility of this new triage tool.

METHODS

In this prospective quality improvement study, nurse call-handlers enrolled febrile children aged 3 months-5 years to video or telephone triage (1:1), with follow-up within 48 h after call. The setting was an out-of-hours call-center for non-urgent illness in Copenhagen, Denmark, receiving over 1 million calls annually and predominately staffed by registered nurses. Main outcome measure was difference in number of children assessed at hospital within 8 h after call between video-and telephone triage group. Rates of feasibility, acceptability and safety (death, lasting means, transfer to intensive care unit) were compared between the triage groups.

RESULTS

There was no difference in triage outcome (home care vs. hospital referral) or number of patients assessed at hospital between triage groups. However, more video triaged patients received in-hospital treatment, testing and hospitalization.

CONCLUSION

Video triage was feasible to conduct, acceptable to parents and as safe as telephone triage. The study did not show that more children stayed at home after video triage, possibly because the allocation strategy was not upheld, as video triage sometimes was chosen in cases of complex and severe symptoms, and this likely has changed study outcome.

TRIAL REGISTRATION

Clinicaltrials.gov.: Id NCT04074239. Registered 2019-08-30. https://clinicaltrials.gov/ct2/show/study/NCT04074239.

"I just haven't experienced anything like this before": A qualitative exploration of callers' interpretation of experienced conditions in telephone consultations preceding a myocardial infarction

OBJECTIVES

Callers with myocardial infarction presenting atypical symptoms in telephone consultations when calling out-of-hours medical services risk misrecognition. We investigated characteristics in callers' interpretation of experienced conditions through communication with call-takers.

METHODS

Recording of calls resulting in not having an ambulance dispatched for 21 callers who contacted a non-emergency medical helpline, Copenhagen (Denmark), up to one week before they were diagnosed with myocardial infarction. Qualitative content analysis was applied.

RESULTS

Awareness of illness, remedial actions and previous experiences contributed to callers' interpretation of the experienced condition. Unclear symptoms resulted in callers reacting to their interpretation by being unsure and worried. Negotiation of the interpretation was seen when callers tested the call-taker's interpretation of the condition and when either caller or call-taker suggested: "wait and see".

CONCLUSION

Callers sought to interpret the experienced conditions but faced challenges when the conditions appeared unclear and did not correspond to the health system's understanding of symptoms associated with myocardial infarction. It affected the communicative interaction with the call-taker and influenced the call-taker's choice of response.

PRACTICE IMPLICATIONS

Call-takers, as part of the decision-making process, could ask further questions about the caller's insecurity and worry. It might facilitate faster recognition of conditions warranting hospital referral.

How parents express their worry in calls to a medical helpline: a mixed methods study

Background

Telephone triage is used globally in out-of-hours primary care, to prioritize who needs urgent assessment. Even though children rarely are severely ill, calls about sick children are among the most prevalent, mainly due to parental worry. Pediatric calls are considered challenging, as the call-handler must rely on parents’ second-hand information. We aimed to investigate if parents’ worry can be used as a predictor of severe illness, and if the content of the calls varies between different grades of worry.

Methods

In a convergent mixed methods study design we asked patients to rate their degree-of-worry before talking to a call-handler. We used quantitative data of degree-of-worry, triage- and patient outcome in pediatric calls (n = 2857), and the qualitative content from 54 calls with subsequent hospitalization ≥24 h.

Results

High degree-of-worry was associated with hospitalization ≥24 h (OR 3.33, 95% CI 1.53–7.21). Qualitative findings both confirmed and expanded knowledge of degree-of-worry. Worry was the predominant cause for contact overall, and was mainly triggered by loss-of-control. In calls with high degree-of-worry, the prevalence of loss-of-control was especially high, and the parents had additionally often contacted healthcare services recently. Parents with a foreign accent often rated their worry as high, and these callers were often ignored or interrupted. Calls with low degree-of-worry seemed to occur early during the disease.

Conclusion

High degree of parental worry was associated with severe illness. At the end of calls, call-handlers should ensure that the parent has regained control of the situation to reach increased reassurance and to prevent renewed unnecessary contact. Safety-netting is crucial, as many parents made contact early during the illness and deterioration may develop later. The scoring of parental degree-of-worry may be used as an indicator of potentially severe illness and can easily be implemented at out-of-hours call-centers globally.

Trial registration

Original study registered at clinicaltrials.gov (NCT02979457).

The effect of telenursing training based on family-centered empowerment pattern on compliance with diet regimen in patients with diabetes mellitus type 2: a randomized clinical trial

BACKGROUND

Telenursing facilitates access to efficient care and acceptance and compliance with treatment at home. Given wide complications of lack of compliance with treatment in causing complications and progression of diabetes and role of the family in attending the patient, this study aimed to investigate the effect of telenursing training based on family-centered empowerment pattern on compliance with diet regimen in patients with diabetes mellitus type 2.

METHODS

This was a randomized controlled clinical trial. The study population was patients with diabetes mellitus type 2 referred to Alzhara hospital at Gilan Gharb in 2019, of which 60 individuals out of them were classified randomly into two groups of intervention and control. Eight 30-min sessions of family-centered training were held through telenursing for the intervention group. Data were gathered before and after the intervention by standard questionnaire of Mudanlo in both groups and was analyzed using SPSS software version 22.

RESULTS

There was no significant difference among the two intervention and control groups before the study regarding demographic variables (p > 0.05). The scores of subscales of making effort for treatment, intention to take the treatment, adaptability, integrating illness into life, stick to the treatment, indecisiveness for applying treatment, and total score of compliance were significantly increased after training intervention (p = 0.001).

CONCLUSIONS

Results of the study indicates positive effects of performing family-centered empowerment pattern using telephone call follow-up on increasing compliance with diet regimen in patients. Therefore, it is recommended to perform family-centered patterns in health policy-makings and also hospitals and other diabetic patients.

Patient safety when receiving telephone advice in primary care – a Swedish qualitative interview study

Background

A lack of patient safety is a significant global public health challenge and is one of the leading causes of death and disability, entailing significant financial and economic costs. However, patient safety can be improved and patients can avoid being harmed if more knowledge could be gained about what it is that impacts patient safety. Patient safety when receiving telephone advice is an important issue given the increase in digitalization in healthcare services.

Aim

The aim of this study was to explore district nurses’ (“telenurses”) experiences and perceptions of patient safety when providing health advice over the phone.

Methods

Data collection was performed using semi-structured interviews and analyzed using qualitative content analysis. The participants (n = 12) were telnurses in primary care.

Results

The theme “Being able to make the right decision” was formed based on two categories: “Communication” and “Assessment”. Through effective communication with the right conditions to make an assessment, the correct decision can be made when a patient calls, and the district nurse feels that their telephone advice is safe for the patient.

Conclusions

Patient safety can be challenged when receiving telephone advice, particularly when they feel stressed due to organizational factors. There is a need to shift from the individual to the organization. Further, while computerized knowledge support generally results in safe decisions, there may also be problems. Hence, it is imperative to develop computerized knowledge support as a part of improved patient safety in telephone advice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00796-9.

Patient satisfaction with telephone care assessment among patients with non-urgent prehospital emergency care issues: A cross-sectional study

BACKGROUND

Telephone care assessment (TCA) by a nurse have shown to reduce the number of emergency department (ED) visits and emergency medical services missions (EMS). The present study aimed to describe satisfaction among patients with non-urgent prehospital medical issues that were transferred to TCA instead of receiving EMS. These results could provide a basis for developing the telephone services and emergency care pathways.

METHODS

This cross-sectional study included 765 patients with non-urgent issues that were transferred to a telephone care assessment, after a risk and urgency assessment by an emergency medical communications operator. One week later, patient satisfaction was evaluated in a structured telephone interview with randomized patients.

RESULTS

127 telephone interviews were completed.Most patients (70.9-85.0%) were highly satisfied with the telephone care assessment. In particular,patients who were unsure of the urgency of their own health condition and the need for EMS, were highly satisfied (95.3%). Patients that received EMS after the telephone care assessment were more satisfied than those that received telephone guidance or those directed to other health care services (91.4% vs. 65.5% vs. 67.9%, p = 0.002).

CONCLUSION

Patients with non-urgent prehospital emergency issues were mainly satisfied with telephone care assessment. In considering ways to reduce the increasing load on emergency medical services, a telephone care assessment could be a good option, without reducing patient satisfaction.

Observational study of the implementation of telephone advice nursing in Sweden: did callers follow recommendations and did the rate of healthcare visits change?

OBJECTIVES

Telephone advice nursing is introduced in many countries with one key aim being a reduction of avoidable healthcare visits. The aim of this study was to explore whether callers to a telephone advice nursing service followed the telenurses' recommendations, and whether there was a change in the level and trend of the rate of healthcare visits after the introduction of telephone advice nursing.

DESIGN

Observational study.

SETTING

Primary and secondary care in Jönköping Region, Sweden.

PARTICIPANTS

Telephone advice nursing calls, 6:00-23:00, 2014-2015 (n=185 994) and outpatient healthcare visits 2012-2015 (n=6 877 266).

PRIMARY OUTCOME

Proportion of callers who visited healthcare within the time period advised by the telenurse.

SECONDARY OUTCOME

Change in level or trend of the overall rate of healthcare visits per 1000 persons and 4-week period after the introduction of telephone advice nursing, with subgroup analysis for primary and secondary care.

RESULTS

77% of callers who were recommended either to visit healthcare within 24 hours or to 'wait and see' followed the recommendations. There was no significant change in level (-5.15; 95% CI -15.80 to 5.50; p=0.349) or trend (-0.24; 95% CI -0.86 to 0.38; p=0.448) of the overall rate of visits per 1000 persons and 4-week period after the introduction of telephone advice nursing. For the rate of primary care visits, an increase in level (8.01; 95% CI 6.36 to 9.66; p<0.001) and trend (1.28; 95% CI 1.17 to 1.39; p<0.001) were observed. For the rate of secondary care visits, a decrease in level (-8.77, 95% CI -14.41 to -3.13; p=0.004) and trend (-1.03, 95% CI -1.35 to -0.71; p<0.001) were observed.

CONCLUSIONS

The introduction of telephone advice nursing may have contributed to a shift in the rate of healthcare visits from secondary to primary care.

Calling an Oncological Emergency Telephone to Seek Advice: An Interview Study

BACKGROUND

Cancer treatment is increasingly provided on an outpatient basis, which may challenge patients and caregivers coping with illness and adverse effects at home. A telephone consultation is an accepted type of healthcare provision to support patients and prevent adverse outcomes when their capacity to self-manage is inadequate. Whether this option for help sufficiently supports patients needs further investigation.

OBJECTIVES

The aim of this study was to explore patients' and caregivers' experience of calling an oncological emergency telephone.

METHODS

The study applies a phenomenological hermeneutic approach with 12 semistructured interviews. Patients and caregivers who had called the oncological emergency telephone within the last 2 months were included. The interview texts were analyzed by content analysis.

RESULTS

Patients and caregivers perceive the emergency telephone as a lifeline that they consider calling when the patient's condition changes from what they understand as normal to what they perceive as abnormal. They would rather call "one time too many than one time too few" if their resources are inadequate to ensure their safety. The tone, attitude, and professional competency of healthcare providers affect patients' experience of the call.

CONCLUSIONS

The value of calling the oncological emergency telephone depends on the healthcare providers' professional competences and skills to establish a relationship that makes patients feeling accommodated and taken care of.

IMPLICATIONS FOR PRACTICE

Patients' and caregivers' perceptions of what constitutes a good telephone consultation represent significant knowledge that contributes to a more comprehensive and practice-based understanding of what is required to advise patients and caregivers in an oncological emergency telephone.

Quality indicators in telephone nursing - An integrative review

Aim

The aim of this study was to identify factors that indicate quality in telephone nursing.

Design

An integrative literature review.

Method

A literature search was performed in October 2018, in the PubMed, CINAHL, Cochrane Library, Academic Search, PsycINFO, Scopus and Web of Science databases. A total of 30 included were included and data that corresponded to the study's aim were extracted and categorized along the three areas of quality as described by Donabedian (Milbank Quarterly, 83, 691), namely structure, process and outcome.

Results

The analysis revealed ten factors indicating quality in telephone nursing (TN): availability and simplicity of the service, sustainable working conditions, specialist education and TN experience, healthcare resources and organization, good communication, person‐centredness, competence, correct and safe care, efficiency and satisfaction. TN services need to target all ten factors to ensure that the care given is of high quality and able to meet today's requirements for the service.

Telephone nurses' strategies for managing difficult calls: A qualitative content analysis

Aim

To describe telenurses' strategies for managing difficult calls.

Background

Telenursing is a growing and complex area and places great demands on telenurses' knowledge and skills and on their ability to communicate and listen. To become emotionally concerned is central to telenurses' experiences of difficult calls.

Design

A descriptive qualitative study.

Methods

The data were collected during February 2017 through individual interviews with 19 telenurses at call centres and primary healthcare centres. Data were analysed with qualitative content analysis.

Result

The analysis revealed an essential strategy illustrated by the theme “to be calm and secure in themselves.” Further categories described telenurses' strategies to manage difficult calls, labelled as: “to show commitment and interest,” “to have structure in the call and use support systems,” “to pause the call” and “to reflect on difficult calls.” The results show that telenurses need multiple strategies to help them to navigate difficult calls.

Telenurses' experiences of interaction with patients and family members: nurse-caller interaction via telephone

BACKGROUND

Telephone nursing is expanding worldwide, but a little is known about nurses' interactions with callers and the factors that affect these interactions.

AIM

The purpose of this paper is to describe how telenurses experience caller interactions.

METHODS

A qualitative study designed through open telephone interviews with call centre nurses (n = 9) in 2017. The data were analysed using inductive content analysis. Ethical guidelines were followed at all stages of the study.

RESULTS

Callers both enhanced and hindered interactions. Nurses' professional skills, such as communication skills, nurse-led control over the call and the nurses' capabilities, enabled positive interactions. Disturbing background sounds, communication problems and service system failures made the telephone interactions challenging. Achieving connection with callers, callers who had supportive family members and a supportive organisational structure were features of successful interactions.

STUDY LIMITATIONS

As all nine participants were recruited from one call centre, the findings are not directly transferable to another environment.

CONCLUSIONS

The results reveal that nurse-caller interactions are affected by several issues concerning the callers and the nurses' skills. Communication problems were often present when telenurses were unable to provide the services callers expected due to lacking health and medical care resources. Family members could be considered important participants in telephone communication with nurses, though further research should examine the possible benefits of interacting with family members.

PRACTICAL IMPLICATIONS

Based on the results of this study, telenurses could benefit from training that focuses on the communication skills that are needed for telephone nursing and the tools needed to meet individual callers' needs. Work environments could also better support caller-nurse interactions. Organisations should provide more resources for telephone nursing in order to promote positive interactions.

To feel emotional concern: A qualitative interview study to explore telephone nurses' experiences of difficult calls

AIM

To describe telenurses' experiences of difficult calls.

DESIGN

A qualitative approach with a descriptive design was used to gain a deeper understanding of the telenurses' experiences.

METHODS

The data were collected in spring 2017 through semi-structured interviews with 19 telenurses at call centres and primary healthcare centres and were analysed with qualitative content analysis.

RESULTS

Becoming emotionally concerned is central to the telenurse's experiences of difficult calls. Difficult calls are accompanied by feelings such as inadequacy, uncertainty and anxiety, which can be described as emotional tension. Emotional tension refers to situations when the caller's expressed emotions were conveyed to the telenurses and altered their state of mind. The telenurses stated that difficult calls that cause them to become anxious remain in their thoughts and go through their minds repeatedly, making a deep impression.

Impact of caller's degree-of-worry on triage response in out-of-hours telephone consultations: a randomized controlled trial

BACKGROUND

Telephone triage entails assessment of urgency and direction of flow in out-of-hours (OOH) services, while visual cues are inherently lacking. Triage tools are recommended but current tools fail to provide systematic assessment of the caller's perspective. Research demonstrated that callers can scale their degree-of-worry (DOW) in a telephone contact with OOH services, but its impact on triage response is undetermined. The aim of this study was to investigate the association between call-handlers' awareness of the caller's DOW and the telephone triage response.

METHODS

A randomized controlled trial at a Danish OOH service using telephone triage with quantitative analyses and qualitative process evaluation. Prior to contact with a call-handler, callers were asked to rate their DOW on a five-point scale. Calls were randomized to show or not show DOW on the call-handlers' screens. Triage response (telephone consultation or face-to-face consultation) was analysed using Chi-square tests. Process evaluation incorporated a quantitative and qualitative assessment of intervention implementation and fidelity.

RESULTS

Of 11,413 calls, 5705 were allocated to the intervention and 5708 to the control group. No difference in number of face-to-face consultations was detected between the two groups (OR 1.05, 95% CI 0.98 to 1.14, p = 0.17). The process evaluation showed that call-handlers did not use the DOW systematically and were reluctant to use DOW.

CONCLUSION

Awareness of DOW did not affect the triage response, but this finding could reflect a weak implementation strategy. Future studies should emphasise the implementation strategy to determine the effect of DOW on triage response.

TRIAL REGISTRATION

Registration number, Clinicaltrials.gov NCT02979457 .

Gaining role clarity in working with sick leave questions-Registered Nurses' experiences of an educational intervention

AIM

To describe how a short educational intervention in social insurance medicine was experienced by Registered Nurses and what changes it brought to their work with sick leave questions in telephone nursing.

DESIGN

Qualitative explorative interview study.

METHODS

Interviews with 12 purposively sampled Registered Nurses were conducted and analysed using manifest content analysis.

RESULTS

The intervention increased Registered Nurses' knowledge of the sick leave process and changed their work habits as they now have more of the skills needed to handle sick leave questions. In this way, they gained role clarity in their work with sick leave questions. The new knowledge included rules and regulations, actors' roles and patients' experiences. Learning from peers, reflecting and having the opportunity to ask questions were also described as increasing their knowledge. The skills following the participation were described as knowing what to say and do and knowing where to turn for support.

Identified obstacles and prerequisites in telenurses' work environment - a modified Delphi study

Background

Telenursing is an expanding part of healthcare, staffed with registered nurses whose work environment is typical of a call centre. Work-related stress has been shown to be a major problem in nurses’ work environments and of importance to the outcome of care, patient safety, nurse job satisfaction and burnout. Today, however, we have a limited understanding of and knowledge about the work environment for telenurses. The aim of the present study is to explore and reach consensus on perceived important obstacles and prerequisites in telenurses’ work environment.

Methods

A modified Delphi design, using qualitative as well as quantitative data sequentially through three phases, was taken. Data were initially collected via semi-structured interviews (Phase I) and later using a web survey (Phase II-III) between March 2015 and March 2016.

Results

The findings present a consensus view of telenurses’ experiences of important obstacles and prerequisites in their work environment. Central to the findings are the aspects of telenurses having a demanding work, cognitive fatigue and having no opportunity for recovery during the work shift was ranked as important obstacles. Highly ranked prerequisites for managing were being able to focus on one caller at a time, working in a calm and pleasant environment and having technical support 24/7.

Conclusions

Managers need to enable telenurses to experience control in their work, provided with possibilities to control their work and to recover during work; shortening work time could improve their work environment. Limited possibilities to perform work might contribute to feelings of stress and inability to perform work.

Bases for assessments made by telephone advice nurses

summary

Telephone advice nursing includes triage, advice, referral, information and coordination. The aim of the study was to explore what telephone nurses base their assessments on. We conducted 14 interviews with seven telephone nurses at a health-care call centre in Sweden. Two authentic calls per nurse were used in stimulated recall interviews, where the nurses commented on the basis for their assessments. A qualitative manifest content analysis was employed. Three major categories emerged in the analysis: care-seeker, e.g. ‘symptomatic sounds’; nurse, e.g. ‘nurse's own experience’; and organization, e.g. ‘health-care accessibility’. The findings show that the telephone advice nurses’ bases for assessments appear to be very broad. They include both verbally and non-verbally communicated information, and care-seeker-, nurse- and certain organization-related factors influence the assessments. We found that an individualistic view of the care-seeker seems to dominate the assessments in non-urgent calls to a health-care call centre.

Registered nurses' work with sick leave questions by telephone in primary health care

AIMS AND OBJECTIVES

To describe registered nurses' work with sick leave questions by telephone.

BACKGROUND

In Sweden, when a sick person needs to request a sickness certification, it is common to contact the primary healthcare centre. The main access to primary health care is by telephone, with a registered nurse answering the care seeker's questions, triaging and helping care seekers to the right level of care. Registered nurses' work with sick leave questions has not been studied, except for two qualitative interview studies.

DESIGN

A descriptive cross-sectional study.

METHODS

A questionnaire with 120 questions was distributed to 185 registered nurses in one county in central Sweden. Descriptive statistics were used for analysis.

RESULTS

Response rate was 62% (n = 114). Registered nurses (n = 105) in this study talked weekly to persons on, or at risk, for sick leave. A large part (n = 78) felt they had a role in the care of persons on sick leave, consisting of booking appointments as well as acting as a pilot, advisor, caretaker and coordinator. For 74 of 114 registered nurses, it was problematic to handle the phone calls weekly. Measures were 'often' booking appointments with physicians (n = 67) and 'seldom' providing information on social insurance rules ('never' n = 51). The registered nurses expressed a great need for more education.

CONCLUSION

Registered nurses in this study reported having a role in the care of persons on sick leave when handling sick leave questions by telephone. The telephone calls were problematic to handle, and the registered nurses expressed a great need for education and training in social insurance medicine.

RELEVANCE TO CLINICAL PRACTICE

There is a need to educate and train registered nurses in social insurance medicine to provide high-quality nursing for patients on or at risk for sick leave.

The meaning of significant others’ encounter with the ambulance clinicians in a non-emergency care context

The ambulance service is often summoned by a significant other. Therefore the ambulance clinician is expected to establish a trusting relationship with her/him and not focus solely on the patient. The aim of this study was to illuminate the meaning of significant others’ encounter with ambulance clinicians in a non-emergency ambulance care context, where patients were triaged to a level of care below that of the Accident and Emergency Department. The design was inductive. We used the phenomenological hermeneutic method developed by Lindseth and Norberg. Eleven significant others were interviewed using an open-ended method. A structural analysis resulted in a total of seven themes, covering the meaning of being de-burdened or the absence of de-burdening. When de-burdened, the significant other was empowered, irrespective of the outcome of the medical assessment and triage process. In the absence of de-burdening, the significant other felt inferior, petty, de-powered and not taken seriously by the ambulance clinicians. The majority of ambulance assignments are considered non-emergency care. The ambulance clinicians are the first to encounter significant others in these situations and therefore have a huge obligation to understand and handle their basic needs.

Registered nurses' experiences of their decision-making at an Emergency Medical Dispatch Centre

AIMS AND OBJECTIVES

To describe registered nurses' experiences at an Emergency Medical Dispatch Centre.

BACKGROUND

It is important that ambulances are urgently directed to patients who are in need of immediate help and of quick transportation to a hospital. Because resources are limited, Emergency Medical Dispatch centres cannot send ambulances with high priority to all callers. The efficiency of the system is therefore dependent on triage. Nurses worldwide are involved in patient triage, both before the patient's arrival to the hospital and in the subsequent emergency care. Ambulance dispatching is traditionally a duty for operators at Emergency Medical Dispatch centres, and in Sweden this duty has become increasingly performed by registered nurses.

DESIGN

A qualitative design was used for this study.

METHODS

Fifteen registered nurses with experience at Emergency Medical Dispatch centres were interviewed. The participants were asked to describe the content of their work and their experiences. They also described the most challenging and difficult situations according to the critical incidence technique. Content analysis was used.

RESULTS

Two themes emerged during the analysis: 'Having a profession with opportunities and obstacles' and 'Meeting serious and difficult situations', with eight sub-themes. The results showed that the decisions to dispatch ambulances were both challenging and difficult. Difficulties included conveying medical advice without seeing the patient, teaching cardio-pulmonary resuscitation via telephone and dealing with intoxicated and aggressive callers. Conflicts with colleagues and ambulance crews as well as fear of making wrong decisions were also mentioned.

CONCLUSIONS

Work at Emergency Medical Dispatch centres is a demanding but stimulating duty for registered nurses.

RELEVANCE TO CLINICAL PRACTICE

Great benefits can be achieved using experienced triage nurses, including increased patient safety and better use of medical resources. Improved internal support systems at Emergency Medical Dispatch centres and striving for a blame-free culture are important factors to attract and retain employees.

The role of helplines in cancer care: intertwining emotional support with information or advice-seeking needs

Helplines are core feature of the contemporary U.K. health care system, however little is known about callers' experiences of seeking cancer-related telephone help. Qualitative interviews were conducted with 32 cancer helpline callers. The findings suggest cancer helplines offer callers (1) time to discuss their issues, (2) anonymity, (3) convenience, and (4) an open outlet for anyone affected by cancer including family/friends. Further, the findings highlighted that callers' help-seeking behavior was multifaceted, with their psychosocial needs being intrinsically intertwined with their information or advice-seeking needs. The implications are discussed in relation to the role of cancer helplines in the healthcare system.

Impact of a telenursing service on satisfaction and health outcomes of children with inflammatory rheumatic diseases and their families: a crossover randomized trial study protocol

BACKGROUND

Pediatric rheumatic diseases have a significant impact on children's quality of life and family functioning. Disease control and management of the symptoms are important to minimize disability and pain. Specialist clinical nurses play a key role in supporting medical teams, recognizing poor disease control and the need for treatment changes, providing a resource to patients on treatment options and access to additional support and advice, and identifying best practices to achieve optimal outcomes for patients and their families. This highlights the importance of investigating follow-up telenursing (TN) consultations with experienced, specialist clinical nurses in rheumatology to provide this support to children and their families.

METHODS/DESIGN

This randomized crossover, experimental longitudinal study will compare the effects of standard care against a novel telenursing consultation on children's and family outcomes. It will examine children below 16 years old, recently diagnosed with inflammatory rheumatic diseases, who attend the pediatric rheumatology outpatient clinic of a tertiary referral hospital in western Switzerland, and one of their parents. The telenursing consultation, at least once a month, by a qualified, experienced, specialist nurse in pediatric rheumatology will consist of providing affective support, health information, and aid to decision-making. Cox's Interaction Model of Client Health Behavior serves as the theoretical framework for this study. The primary outcome measure is satisfaction and this will be assessed using mixed methods (quantitative and qualitative data). Secondary outcome measures include disease activity, quality of life, adherence to treatment, use of the telenursing service, and cost. We plan to enroll 56 children.

DISCUSSION

The telenursing consultation is designed to support parents and children/adolescents during the course of the disease with regular follow-up. This project is novel because it is based on a theoretical standardized intervention, yet it allows for individualized care. We expect this trial to confirm the importance of support by a clinical specialist nurse in improving outcomes for children and adolescents with inflammatory rheumatisms.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT01511341 (December 1st, 2012).

Documentation of Nursing Care in Advanced Home Care

Nursing documentation in advanced home care (AHC) is essential in communication between nurses and interprofessionally for evaluation of patient care. Poor documentation could be a threat to high quality care and patient safety. The aim of this study was to describe documentation of nursing care within AHC. Sixty nursing records from two AHC-units in Sweden were collected and a content analysis was performed. The results revealed documentation from a broad spectrum of advanced nursing care, consisting of both planned and acute care. However, the documentation was often fragmented and information sometimes hard to find. Nursing documentation often described caring needs, but lacked interventions and evaluations. Further development and research on nursing documentation and its connection to evidence-based practice within AHC is needed.

Feeling rejected or invited: experiences of persons seeking care advice at the Swedish Healthcare Direct organization

AIM

Swedish Healthcare Direct is an organization staffed by registered nurses who act as telenurses and assess callers' need for care, taking both medical and personal aspects into account. They direct the care seeker to: emergency care (level I), a care center on duty (level II), their regular doctor (level III), or provide advice about self-care strategies (level IV). In this assessment process, the nurse and care seeker should reach mutual agreement. The aim and focus of the present study was to elucidate the care seeker's situation and experiences of the care received after being triaged and directed to level II, although the telenurse in fact assessed their medical problems as corresponding to level III.

METHODS

A total of eight recent Swedish Healthcare Direct users were interviewed in this qualitative study. Data were analyzed by means of content analysis.

RESULTS

Three themes emerged - "feeling trapped", "feeling disrespected", and "feeling invited" - comprising seven subthemes.

CONCLUSION

Care seekers experienced suffering as well as struggling to be allowed to be a patient. When not met by an ethically correct stance, they continued to seek care. In contrast, when they encountered commitment and an ethically correct attitude, their health process began and they had no further need for contact.

Exploring challenges to telehealth communication by specialists in poison information

The use of the telephone for providing health care is growing. A significant amount of social meaning is derived from visual information, and the absence of visual stimuli provides unique barriers to communication and increases the risks for misunderstandings and distractions. Understanding challenges to telephone communication can provide insight into training opportunities for overcoming these difficulties and improving patient care. The purpose of this research was to explore through focus groups the challenges of phone communication perceived by specialists in poison information. General types of challenges to effective phone communication included developing new communication skills to compensate for lack of visual information, difficulty assessing caller understanding, difficulty managing caller misunderstandings, maintaining distinctive assessments for routine calls, and managing the multifaceted aspects of job stress. The desire for training to enhance telehealth and cultural competency skills was also mentioned, and these findings might provide guidance for the development of training opportunities for telehealth professionals.

Triage and patient satisfaction among callers in Swedish computer-supported telephone advice nursing

We investigated satisfaction with a Swedish telenursing service and the health-care-seeking behaviour among callers who received a less urgent level of health care than they expected. A postal questionnaire was sent to a random selection of callers ( n = 273) to Swedish Healthcare Direct in October 2008. The ‘cases’ were 18 callers where the telenurse recommended a lower level of health care than the caller expected and who were not in complete agreement with the nurse. The ‘controls’ were 22 callers who either received a lower recommendation, or were in disagreement with the recommendation. There were no differences between cases, controls and other callers regarding background factors or the telenurse classification of emergency. However, both cases and controls considered their need for health care as more urgent than the other callers. An independent test of the nurses' reception, ability to listen and to take notice of the callers' health problem, showed that nurses who had served cases, had received a significantly lower rating than other nurses. For nurses who had served controls, there was no such difference in rating. Cases and controls had fewer subsequent care visits than other callers, in the three days following the call, although the proportion of emergency visits was higher among cases and controls compared to other callers. If the caller and the nurse disagree about the nurse's recommendations, the consequence can be a dissatisfied caller and more visits to unnecessary high levels of health care. Further training of the nurses may improve the telenurse service.

Understanding of and adherence to advice after telephone counselling by nurse: a survey among callers to a primary emergency out-of-hours service in Norway

BACKGROUND

To investigate how callers understand the information given by telephone by registered nurses in a casualty clinic, to what degree the advice was followed, and the final outcome of the condition for the patients.

METHODS

The study was conducted at a large out-of-hours inter-municipality casualty clinic in Norway during April and May 2010. Telephone interviews were performed with 100 callers/patients who had received information and advice by a nurse as a sole response. Six topics from the interview guide were compared with the telephone record files to check whether the caller had understood the advice. In addition, questions were asked about how the caller followed the advice provided and the patient's outcome.

RESULTS

99 out of 100 interviewed callers stated that they had understood the nurse's advice, but interpreted from the telephone records, the total agreement for all six topics was 82.6%. 93 callers/patients stated that they followed the advice and 11 re-contacted the casualty clinic. 22 contacted their GP for the same complaints the same week, of whom five patients received medical treatment and one was hospitalised. There were significant difference between the native-Norwegian and the non-native Norwegian regarding whether they trusted the nurse (p = 0.017), and if they got relevant answers to their questions (p = 0.005).

CONCLUSION

Callers to the out-of-hours service seem to understand the advice given by the registered nurses, and a large majority of the patients did not contact their GP or other health services again with the same complaints.

PRACTICE IMPLICATION

Medical and communicative training must be an important part of the continuous improvement strategy within the out-of-hour services.

A qualitative study exploring the nurse telephone follow-up of patients returning home with a colostomy

AIM

The aim of this study was to explore and describe the content of telephone intervention conversations conducted by an enterostomal nurse with patients discharged home with a colostomy.

BACKGROUND

People discharged home with a new colostomy often encounter stoma-related difficulties. Postdischarge care with telephone follow-up by an enterostomal nurse is a helpful way to provide support for patients and ensure continuity of care. There is a paucity of studies reporting the content of telephone follow-up of colostomy patients. Information on the content of such follow-up is important in helping to formulate telephone call protocols that can help these patients.

DESIGN

A qualitative exploratory study conducted in a university-based cancer centre in China.

METHODS

The contents of 25 intervention phone calls to colostomy patients from January-August 2009 were subject to qualitative content analysis.

RESULTS

Five themes emerged from the qualitative content analysis: 'education for stoma care', 'access to stoma care', 'encouraging stoma self-care', 'resuming normal living' and 'general postoperative problems'.

CONCLUSIONS

Colostomy patients experienced stoma-related problems and difficulties after discharge, most of which could be effectively managed via telephone follow-up by an enterostomal nurse. The telephone follow-up satisfied patients' need for information and facilitated their adjustment to the permanent stoma. The findings suggested that patients had unmet needs after discharge and needed follow-up on returning home.

RELEVANCE TO CLINICAL PRACTICE

This study provides important information to guide practice and education. The themes extracted from the qualitative content analysis provide a useful framework to guide the nurse in discussing care with the stoma patients and ensuring patients' adjustment to the permanent stoma. Further work can be done using this framework to develop protocols as standards of care and education materials when educating nurse specialists in stoma care.

Demonstration of facial communication of emotion through telehospice videophone contact

PURPOSE

The purpose of this study was to demonstrate the range of emotional expressions that can be displayed by nurse and family caregiver during a telehospice videophone consultation. We hypothesized that a nurse providing telehospice care via videophone would gain access to rich nonverbal emotional signals from the caregiver and communicate her own social presence to the caregiver, to potentially enhance the building of empathy between nurse and caregiver.

METHODOLOGY

Videorecording of a case exemplar of videophone contact was obtained using the Beamer, a commercially available product that allows display of both caller and receiver on an available television through standard telephone lines. Nonverbal communication through facial expressions of emotion was quantified using detailed coding of facial movement and expression (facial action coding system).

RESULTS

In this study, we demonstrated the presence of visual nonverbal information in the form of facial expressions of emotion during a videophone interaction between nurse and family caregiver. Over the course of a typical after-hours telehospice call, a variety of facial expressions of emotion were displayed by both nurse and family caregiver. Expression of positive and negative emotions, as well as mixed emotions, was apparent. Through detailed analysis of this case of videophone interaction, we have demonstrated the potential value of videophone contact for providing access to visual nonverbal emotional communication.

Paediatric health calls to Swedish telenurses: a descriptive study of content and outcome

We collected data about telephone triage calls concerning children in Sweden. A sample of 110 paediatric calls were recorded. The transcribed data were analysed regarding word count, reasons for calling, results of calls, ages and gender of children, and gender of parents. The median call length was 4.4 min and the median child's age was 3.5 years. Mothers made 73% of calls, but mothers and fathers called to the same extent about daughters and sons, and regardless of age. The most common reasons for calls were ear problems, rash/wound or fever. In nearly half the calls, the telenurses provided self-care advice. Call length, word count or caller's part of word count did not differ according to gender of parents or children. However, mothers were more likely to receive self-care advice while fathers were more often referred to other health services by the telenurses. Telenurses might need to improve their gender competence, and more male telenurses in the service would potentially be beneficial to callers.

Nurses' experiences with telephone triage and advice: a meta-ethnography

AIMS

This study is a meta-ethnography of nurses' experiences with telephone triage and advice and factors that facilitate or impede their decision-making process.

BACKGROUND

Telephone triage and advice services are a rapidly expanding development in health care. Unlike traditional forms of nursing practice, telenurses offer triage recommendations and advice to the general public without visual cues.

DATA SOURCES

Published qualitative research on telephone triage and advice were sought from interdisciplinary research databases (1980-2008) and bibliographical reviews of retrieved studies.

REVIEW METHODS

Our systematic search identified 16 relevant studies. Two researchers independently reviewed, critically appraised, and extracted key themes and concepts from each study. We followed techniques of meta-ethnography to synthesize the findings, using both reciprocal and refutational translation to compare similar or contradictory findings, and a line-of-arguments synthesis.

RESULTS

We identified five major themes that highlight common issues and concerns experienced by telenurses: gaining and maintaining skills, autonomy, new work environment, holistic assessment, and stress and pressure. A line-of-arguments synthesis produced a three-stage model that describes the decision-making process used by telenurses and highlights how assessments largely depend on the ability to 'build a picture' of the patient and the presenting health issue.

CONCLUSION

Telenurses experience a range of common concerns and issues which either impede or facilitate the decision-making process. Although 'building a picture' of the patient is key to making assessments over the telephone, final triage decisions are influenced by balancing the conflicting demands of being both carer and gatekeeper to limited healthcare services.

The Impact of Work Environment on Telephone Advice Nursing

Telephone advice nursing (TAN) is part of a current effort to improve patient access while reducing cost and encouraging self-care. However, the environment in which TAN occurs can significantly affect both nurse and patient outcomes. This research builds on findings from a large health maintenance organization study by Valanis et al. in which questionnaires and call descriptions were used to correlate TAN nurse and caller/patient perceptions of calls at three regional sites. The survey tools were used to identify nurse perceptions of their work environments (WEs) as well as caller perceptions of using the advice service. The sample included 88 nurse questionnaires and 865 caller questionnaires. Multivariate analysis of covariance revealed significant site perception differences in the WE of stress, communication, and autonomy, whereas no significant differences were noted in collegial relationships and organizational support. Each site was also determined to be a unique predictor of patient perceptions of satisfaction with the advice. Findings indicate nursing professionals act as a filter to mask stressful WE effects experienced by nurses and ensure patient outcomes thereby supporting patient satisfaction with the service.

Incident reporting in nurse-led national telephone triage in Sweden: the reported errors reveal a pattern that needs to be broken

We conducted a retrospective study of incident reports concerning the national, nurse-led telephone triage system in Sweden. The Swedish Health Care Direct organization (SHD) is staffed by registered nurses who act as telenurses and triage the callers' need for care, using a computerized decision support system. Data were collected during 2007 from all county councils that participated in the SHD and were analysed using content analysis. Incident reports were then compared concerning differences in reported categories and who reported the errors. The 426 incident reports included 452 errors. Of the analysed incident reports, 41% concerned accessibility problems, 25% incorrect assessment, 15% routines/guidelines, 13% technical problems and 6% information and communication. The most frequent outgoing incident reports (i.e. sent from SHD to other health-care providers) concerned accessibility problems and the most frequently incoming reports (i.e. sent to SHD from other health-care providers) concerned incorrect assessment. There was a significant difference (P < 0.001) between outgoing and incoming reports regarding the main category. Telenurses have limited possibilities for referring the caller to their primary health-care provider or specialist, which may cause them to over-triage or under-triage the callers' need for care. This over-triage or under-triage may in turn cause other health-care providers to report incorrect assessment to SHD. The implications for practice are that poor accessibility is a matter that should be addressed and that the reasons for incorrect assessment should be explored.

Alternative delivery methods for pharmacy services

In many developed countries, the provision of pharmacy services is no longer restricted to the traditional “walk-in” or face-to-face approach. This paper examines whether alternative delivery methods provide patients with pharmacy services that meet their medication and related information needs, and discusses professional issues and the implications for practice. Although not appropriate for everyone, studies show that many patients do accept the alternative means of service delivery examined here. For some patients, such as those with mobility problems or who live in remote areas, technology-driven alternatives may be preferred. Health care professionals must take steps to address legitimate concerns about the protection of patient safety and confidentiality. To increase patient choice, the pharmacy profession needs to look closely at the positive aspects of these alternatives, as they can be incorporated in “traditional” pharmacy practice.

Physical and digital proximity: emerging ways of health care in face-to-face and telemonitoring of heart-failure patients

The introduction of telehealth-care technologies profoundly changes existing practices of care. This paper aims to enhance our understanding of these changes by providing a comparative study of health-care services for heart-failure patients based on face-to-face contacts in a policlinic (department of a health care facility treating outpatients) and remote consultations at a telehealth-care centre. I will show how changes that take place when care moves from physical to virtual clinical encounters cannot be understood in terms of a replication of existing health-care services. Instead, it is more useful to conceptualise these health-care provisions as practices that create and value other kinds of care, incorporating different forms of proximity to patients. The physical proximity created at the policlinic facilitates contextualised, personalised care in which responsibilities for monitoring are delegated to nurses and patients and heart failure is constituted as an illness. The digital proximity that characterises the telehealth-care centre supports individualised, immediate care in which responsibilities are largely delegated to technological devices and heart failure is constituted as a disease. A major policy implication of these differences is that telehealth-care cannot simply replace physical consultations without changing the nature of health care.

Real nursing? The development of telenursing

AIM

This paper is a report of a study to understand the impact of telenursing from the perspective of nurses involved in its provision, and in more traditional roles.

BACKGROUND

Nurse-led telephone helplines have recently been introduced across the United Kingdom, a major step in the development of nursing practice.

METHOD

A structured questionnaire was sent to all nurses working in the NHS Direct (National Health Service Direct) Wales telephone service (n = 111). Ninety-two completed questionnaires were returned (response rate 83 per cent). Two focus groups were conducted: one with telephone service nurses (n = 8) and one with other nurses (n = 5). The data were collected in 2002.

FINDINGS

Respondents represented a highly educated workforce from a range of healthcare specialties. They reported that they joined the telephone service for improved salary and flexible working. Two-thirds reported improved job satisfaction. All focus group participants reported that the development of nursing skills was affected by the use of decision support software and the remote nature of the consultation. Participants reported opportunities for skill development, although the role could be stressful. All agreed that the service was popular with callers, but the nurses from outside raised concerns about whether telenursing was 'real' nursing and about the evidence base for the service and access by disadvantaged groups.

CONCLUSION

Differences between the groups reflect policy tensions between the need to develop new nursing skills, including the use of technology, to improve efficiency and recognition of the worth of hands-on nursing. These tensions must be addressed for the telephone service to function as part of an integrated healthcare system.