Resurfacing the care in nursing by telephone: lessons from ambulatory oncology

Triage as an infrastructure of care: The intimate work of redistributing medical care in nursing homes

This article explores how professionals in older persons care work on a triage system in the daily care setting. We follow how triage is introduced in older persons care organizations in The Netherlands, to deal with a scarcity of physicians and distribute care among health workers in the region. We offer a sociological analysis in which we use the notion of infrastructure and infrastructural work to study how professionals work with triage in the daily care setting. This study is based on a formative evaluation in which we as researchers both studied and contributed to the construction of the triage system by sharing and participating in reflexive infrastructural work practices. We show how this method enabled to gradually adjust the triage system to the daily practices of care delivery, taking the spatial-temporal setting of care into account. We argue that triage not only structures and simplifies but also opens up new ways of re-placing medical and care work, both professionally and geographically. As our results reveal, re-placing physicians has complex effects above and beyond the efficient deployment of medical staff. Triage as infrastructure not only changes the location, but also reconfigures the relationships physicians have with residents and nurse aids.

Research priorities for the pan-Canadian Oncology Symptom Triage and Remote Support practice guides: a modified nominal group consensus

Introduction

The pan-Canadian Oncology Symptom Triage and Remote Support (costars) team is studying how to improve the quality and consistency of cancer symptom management.

Methods

A 1-day invitational meeting was held 24 October 2017 in Ottawa, Ontario, to review the current evidence from costars projects and to establish research priorities for a future largescale implementation study. The meeting included 36 participants who were clinicians from adult oncology, pediatric oncology, and homecare; policymakers from national, provincial, and regional organizations; researchers; and a patient. Half the day involved summarizing evidence from four costars studies and experiences with implementing the costars symptom practice guides. The second half of the day used a modified nominal group technique to generate research questions within small groups, presentation of research questions to all participants, and two rounds of voting to reach consensus on research priorities.

Results

Participants proposed 4 research categories:■ User-centred augmentation to enhance usability (for example, designing a mobile costars solution)■ Outcome measurement (for example, determining key competencies for clinicians)■ Regular renewal of costars to keep pace with evolving evidence (for example, updates for novel therapies)■ Integration into clinical practice (for example, meaningful engagement of patients and caregivers in study design).

Conclusions

Across categories, the top 3 priorities were effect on health services use, competency development, and a mobile costars solution. Future research will address identified priorities, reflecting the needs and perspectives of diverse stakeholders. Stakeholder collaboration will continue to guide our approach to operationalizing this priority research agenda.

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.

Standardization of Telephone Triage in Pediatric Oncology

Nurses in pediatric oncology are often the main resource for overwhelmed parents and deal with complex patient issues over the telephone but often not without concerns about best patient care, liability, and accountability for the advice given. The question is whether using standardization of telephone triage practices can provide opportunities for improvement in the care of pediatric oncology patients. A review of the literature pertaining to telephone triage, standardization of practice, and the practice in outpatient oncology was conducted. The utilization of easy-to-use, accessible yet nonrestrictive resources and a well-designed documentation tool can help guide the decision-making process while addressing legal concerns and ensuring best possible patient care. An advantage that nurses in outpatient oncology settings have in performing telephone triage is the knowledge they have of their patient population and the disease process and treatments. Using a balanced approach to standardization of telephone triage practices can provide opportunities for improvements in care while still capitalizing on the intuitive knowledge and experience of the nurses involved.

A psychosocial oncology program: perceptions of the telephone-triage assessment

PURPOSE

Cancer can be a significant source of distress for patients and family members, which led to the creation of psychosocial oncology (PSO) programs across Canada. To access the PSO program at this institution, individuals are first triaged over the telephone by a clinical nurse specialist (CNS) who also provides psychosocial support during the call. In our study, we explored the perceptions of cancer patients or family members about their psychosocial telephone-triage assessment conducted by a CNS for a PSO program.

METHODS

A qualitative descriptive design was used to explore the perceptions of nine cancer patients and family members triaged by the CNS for the PSO program. Audiotaped in-person interviews were transcribed verbatim and analyzed for themes and categories using a constant comparative method.

RESULTS

Three major themes emerged: (1) Triage as a bridge to care, referred to the structure of telephone-triage and link to psychosocial services; (2) feeling a supportive presence, referred to the CNS' actions to foster a therapeutic relationship; and (3) different paths to tailored care, referred to the individualized strategies targeted to the participant's unique needs. As most participants described trusting the CNS, these three themes were found to emerge through a lens of trust.

CONCLUSION

Overall, the telephone triage was able to address the concerns of many participants and provide individualized coping strategies and support. This study further demonstrates that psychosocial support can be provided during triage over the telephone.

Patient and family experiences with accessing telephone cancer treatment symptom support: a descriptive study

PURPOSE

Assess patient and family member experiences with telephone cancer treatment symptom support.

METHODS

Descriptive study guided by the Knowledge-to-Action Framework. Patients and family members who received telephone support for a cancer treatment symptom within the last month at one of three ambulatory cancer programs (Nova Scotia, Ontario, Quebec) were eligible. An adapted Short Questionnaire for Out-of-hours Care instrument was analyzed with univariate statistics.

RESULTS

Of 105 participants, 83 % telephoned about themselves and 17 % for a family member. Participants received advice over the telephone (90 %) and were advised to go to emergency (13 %) and/or the clinic (9 %). Two left a message and were not called back. Participants were "very satisfied" with the manner of nurse or doctor (58 %), explanation about problem (56 %), treatment/advice given (54 %), way call was handled (48 %), getting through (40 %), and wait time to speak to a nurse or doctor (38 %). The proportion "dissatisfied" or "very dissatisfied" for the above items was 4, 5, 9, 11, 10, and 14 %, respectively. Suggestions were shorter call back time, weekend access to telephone support, more knowledgeable advice on self-care strategies, more education at discharge, and shared documentation on calls to avoid repetition and improve continuity.

CONCLUSIONS

Most patients and family members who responded to the survey were satisfied with telephone-based cancer treatment symptom support. Programs could improve telephone support services by providing an estimated time for callback, ensuring that nurses have access to and use previous call documentation, and enhancing patient education on self-care strategies for managing and triaging treatment-related symptoms.

Redesigning Advanced Cancer Care Delivery: Three Ways to Create Higher Value Cancer Care

The authors believe their cancer care model constructed from quality-improving strategies has potential to help US clinicians respond effectively to an urgent policy imperative.

Telephone calls postdischarge from hospital to home: a literature review

The oncology population is particularly affected by hospital readmissions because hospitalized patients with cancer often have complex needs. The complexity and diversity of care requirements create substantial challenges in planning for appropriate postdischarge support. Implementing postdischarge telephone calls in the population of patients with cancer could offer a low-cost intervention to address the complex needs of patients during the transition from hospital to home. The goal of the current literature review is to provide an understanding about postdischarge telephone calls in patients with cancer. Findings from this review support the notion that discharge phone calls could improve care continuity for patients transitioning from hospital to home. The literature review outlines information related to telephone call content, timing, and structure for healthcare systems that want to use a postdischarge telephone intervention for patients with cancer. However, additional research is needed to develop and test cancer-specific protocols.

Development and evaluation of evidence-informed clinical nursing protocols for remote assessment, triage and support of cancer treatment-induced symptoms

The study objective was to develop and evaluate a template for evidence-informed symptom protocols for use by nurses over the telephone for the assessment, triage, and management of patients experiencing cancer treatment-related symptoms. Guided by the CAN-IMPLEMENT© methodology, symptom protocols were developed by, conducting a systematic review of the literature to identify clinical practice guidelines and systematic reviews, appraising their quality, reaching consensus on the protocol template, and evaluating the two symptom protocols for acceptability and usability. After excluding one guideline due to poor overall quality, the symptom protocols were developed using 12 clinical practice guidelines (8 for diarrhea and 4 for fever). AGREE Instrument (Appraisal of Guidelines for Research and Evaluation) rigour domain subscale ratings ranged from 8% to 86% (median 60.1 diarrhea; 40.5 fever). Included guidelines were used to inform the protocols along with the Edmonton Symptom Assessment System questionnaire to assess symptom severity. Acceptability and usability testing of the symptom populated template with 12 practicing oncology nurses revealed high readability (n = 12), just the right amount of information (n = 10), appropriate terms (n = 10), fit with clinical work flow (n = 8), and being self-evident for how to complete (n = 5). Five nurses made suggestions and 11 rated patient self-management strategies the highest for usefulness. This new template for symptom protocols can be populated with symptom-specific evidence that nurses can use when assessing, triaging, documenting, and guiding patients to manage their-cancer treatment-related symptoms.

Managing symptoms during cancer treatments: evaluating the implementation of evidence-informed remote support protocols

BACKGROUND

Management of cancer treatment-related symptoms is an important safety issue given that symptoms can become life-threatening and often occur when patients are at home. With funding from the Canadian Partnership Against Cancer, a pan-Canadian steering committee was established with representation from eight provinces to develop symptom protocols using a rigorous methodology (CAN-IMPLEMENT©). Each protocol is based on a systematic review of the literature to identify relevant clinical practice guidelines. Protocols were validated by cancer nurses from across Canada. The aim of this study is to build an effective and sustainable approach for implementing evidence-informed protocols for nurses to use when providing remote symptom assessment, triage, and guidance in self-management for patients experiencing symptoms while undergoing cancer treatments.

METHODS

A prospective mixed-methods study design will be used. Guided by the Knowledge to Action Framework, the study will involve (a) establishing an advisory knowledge user team in each of three targeted settings; (b) assessing factors influencing nurses' use of protocols using interviews/focus groups and a standardized survey instrument; (c) adapting protocols for local use, ensuring fidelity of the content; (d) selecting intervention strategies to overcome known barriers and implementing the protocols; (e) conducting think-aloud usability testing; (f) evaluating protocol use and outcomes by conducting an audit of 100 randomly selected charts at each of the three settings; and (g) assessing satisfaction with remote support using symptom protocols and change in nurses' barriers to use using survey instruments. The primary outcome is sustained use of the protocols, defined as use in 75% of the calls. Descriptive analysis will be conducted for the barriers, use of protocols, and chart audit outcomes. Content analysis will be conducted on interviews/focus groups and usability testing with comparisons across settings.

DISCUSSION

Given the importance of patient safety, patient-centered care, and delivery of quality services, learning how to effectively implement evidence-informed symptom protocols in oncology healthcare services is essential for ensuring safe, consistent, and effective care for individuals with cancer. This study is likely to have a significant contribution to the delivery of remote oncology services, as well as influence symptom management by patients at home.

Emergency department visits for symptoms experienced by oncology patients: a systematic review

PURPOSE

The aim of this review was to explore the range and prevalence of cancer treatment or disease-related symptoms in the emergency department and their associated outcomes.

METHODS

A systematic review examined studies cited in Medline, Embase, PsycINFO, and CINAHL published from 1980 to July 2011. Eligible studies measured emergency department visits for symptom assessment in adult oncology patients. Two reviewers independently screened citations and double data extraction was used. Descriptive analysis was conducted.

RESULTS

Of 1,298 citations, six prospective and 12 retrospective descriptive studies were included. Of these, eight focused on multiple symptoms and 10 targeted specific symptoms. The studies were published between 1995 and 2011, conducted in seven countries, and had a median sample size of 143 (range 9-27,644). Of the 28 symptoms reported, the most common were febrile neutropenia, infection, pain, fever, and dyspnea. Definitions provided for individual symptoms were inconsistent. Of 16 studies reporting admission rates, emergency visits resulted in hospital admissions 58 % (median) of the time in multi-symptom studies (range 31 % to 100 %) and 100 % (median) of the time in targeted symptoms studies (range 39 % to 100 %). Of 11 studies reporting mortality rates, 13 % (median) of emergency visits captured in multi-symptom studies (range 1 % to 56 %) and 20 % (median) of visits in targeted symptoms studies (range 4 % to 67 %) resulted in death.

CONCLUSIONS

Individuals with cancer present to emergency departments with a myriad of symptoms. Over half of emergency department visits resulted in hospital admissions. Few symptoms were defined adequately to compare data across studies, thereby revealing an important gap in cancer symptom reporting.

The complexity of non face-to-face work with patients affected by metastatic breast cancer and their carers. The 'hidden consultations' of the clinical nurse specialist

INTRODUCTION

Survival rates in breast cancer have risen in the last 30 years. Almost one third of those diagnosed will go onto developing metastatic breast cancer which is becoming a long term condition in cancer care. In 2006 429,000 new cases of breast cancer were recorded across Europe. In recent years treatment for metastatic breast cancer in the UK has moved to the ambulatory setting meaning non face-to-face contact, for example through telephone consultation, has become a vital method of management.

METHOD

A prospective study conducted over a 1-month period at a London Trust. Data was collected by two clinical nurse specialists on incoming calls using Excel and a bespoke interrelational structured query database. These data were then mined using standard data mining techniques.

RESULTS

The study collected 28 days of data. 229 patient and carer telephone contacts were recorded across the Trust. Most calls were from patients (62.5%). Incoming calls resulted in the delivery of 1282 interventions, a mean of six interventions per call (range 1-8) and clustered into four areas: meeting information needs (29%), symptom management (26%), psychological/social issues (33%) and other issues (12%). The incoming telephone work accounted for 63 h which represented 30% of the total working time of the clinical nurse specialist. Calls primarily originated from patients who were in the follow-up phase (43% of calls), a group usually thought to prefer self management.

Tele-practice guidelines for the symptom management of children undergoing cancer treatment

The provision of tele-practice symptom management is often without the provision of evidence-based guidelines. Under the auspices of the Pediatric Oncology Group of Ontario, a nursing task force was established to appraise the evidence and develop guidelines. Promising new efforts to enhance symptom management through tele-practice are emerging. Seven guidelines and one documentation tool were created from evidence compiled from case reports, clinical examples, and nonexperimental studies. The symptom management guidelines contribute to the paucity of literature and may serve as a useful resource for health professionals providing telephone advice and conducting tele-practice symptom management assessments.

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.

Prostate cancer telephone helpline: nursing from a different perspective

Prostate cancer is now the most common male cancer in the UK with 32000 men diagnosed annually (Cancer Research UK, 2006). The increasing numbers of men diagnosed, as well as those requiring ongoing support, places a huge burden on NHS services. The best options for managing the disease are not yet known, and the development of newer treatments has increased the difficulty men face in making the right choice. The important role The Prostate Cancer Charity's confidential nurse-led helpline plays in providing information and support to men and their families will be demonstrated in this article. The specialist nurses who deliver this service are highly skilled, knowledgeable and experienced. The training and support they need to deliver this service effectively is provided through a variety of methods which will be described. Our priority is to assure the ongoing quality is maintained for every caller and an effective skill set is maintained.

Nursing telephone triage and its influence on parents' choice of care for febrile children

Nursing telephone triage is a mechanism whereby parents call for advice and referrals. One common call in pediatrics concerns children's fever, which may be managed at home. Giving parents proper advice may avoid unnecessary visits. This study investigated whether home-care advice given by nurses changed parents' original preference for care. Data were collected using an existing database to determine parents' preference for location of care before and actual location of care after a call. Of the 110 calls, 73 parents wanted a physician or emergency department visit but 53 followed nursing advice for home care. Findings suggest that although most parents wanted to have their child seen, a majority followed nursing advice for home care.

Nurses' views of using computerized decision support software in NHS Direct

BACKGROUND

Nurses working in NHS Direct, the 24-hour telephone advice line in England, use computerized decision support software to recommend to callers the most appropriate service to contact, or to advise on self-care.

AIMS

To explore nurses' views of their roles and the computerized decision support software in NHS Direct.

METHODS

Qualitative analysis of semi-structured interviews with 24 NHS Direct nurses in 12 sites.

FINDINGS

Nurses described both the software and themselves as essential to the clinical decision-making process. The software acted as safety net, provider of consistency, and provider of script, and was relied upon more when nurses did not have clinical knowledge relevant to the call. The nurse handled problems not covered by the software, probed patients for the appropriate information to enter into the software, and interpreted software recommendations in the light of contextual information which the software was unable to use. Nurses described a dual process of decision-making, with the nurse as active decision maker looking for consensus with the software recommendation and ready to override recommendations made by the software if necessary. However, nurses' accounts of the software as a guide, prompt or support did not fully acknowledge the power of the software, which they are required to use, and the recommendation of which they are required to follow under some management policies. Over time, the influence of nurse and software merges as nurses internalize the software script as their own knowledge, and navigate the software to produce recommendations that they feel are most appropriate.

CONCLUSIONS

The nurse and the software have distinct roles in NHS Direct, although the effect of each on the clinical decision-making process may be difficult to determine in practice.