National Telephone Advice Nursing in Sweden
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To Robin and Maja List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Ernesäter A, Holmström I K, Engström M. Telenurses’ expe- riences of working with computerized decision support: supporting, inhibiting and quality improving. J Adv Nurs 2009; 65:1074-83. II Ernesäter A, Engström M, Holmström I K, Winblad U. Inci- dent reporting in nurse-led national telephone triage in Swe- den: the reported errors reveal a pattern that needs to be bro- ken. J Telemed Telecare 2010; 16:243-47 III Ernesäter A, Engström M, Winblad U, Rahmqvist M & Holmström I K. Communication challenges in Swedish tele- phone advice nursing – analysis of actual calls. Submitted. IV Ernesäter A, Winblad U, Engström M & Holmström I K. Malpractice claims regarding calls to Swedish telephone ad- vice nursing: what went wrong and why? Accepted for publi- cation in Journal of Telemedicine and Telecare (2012) Reprints have been made with kind permission from the respective publish- ers. Contents Introduction ..................................................................................................... 9 Telephone advice nursing ......................................................................... 10 Clinical decision-making ..................................................................... 13 Patient safety and patient safety work ...................................................... 14 Communication ........................................................................................ 17 Communication within healthcare ....................................................... 17 Communication within telephone advice nursing ............................... 19 Analyzing healthcare communication ................................................. 21 Rationale for this study ............................................................................ 22 Overall and specific aims .............................................................................. 23 Methods ........................................................................................................ 24 Design ...................................................................................................... 24 Setting .................................................................................................. 24 Sample and Material ............................................................................ 25 Data collection ..................................................................................... 26 Data analysis ........................................................................................ 27 Ethical considerations .............................................................................. 30 Results ........................................................................................................... 31 Discussion ..................................................................................................... 36 Patient safety in telephone advice nursing ............................................... 37 Communication in telephone advice nursing ........................................... 39 Methodological considerations ..................................................................... 44 Conclusions ................................................................................................... 47 Clinical implications ..................................................................................... 48 Sammanfattning (Summary in Swedish) ...................................................... 50 Acknowledgements ....................................................................................... 52 References ..................................................................................................... 54 Introduction The three-year-old boy became ill, with stomach pain and vomiting. He whined and complained of pain. His mother called SHD since she perceived that her son’s stomach pain was more than just normal gastroenteritis. She received reassurance and self-care advice as she would in the case of gastro- enteritis. A couple of hours later she called again. She told the telenurse how her son had stopped vomiting, that he was lying with his eyes open and “ap- peared unconscious” with pale, cold skin and blue lips. Yet again she was given reassurance and self-care advice. After the third call she was advised to go to the emergency department. The child was dead on arrival. (From DN 2009) As illustrated, making assessments via the telephone is one of the most diffi- cult and complex work assignments for nurses. My interest in this area arose when in my clinical work as a district nurse I worked at an on-call clinic in Gävle, and one of my duties was telephone advice nursing. During this work I sometimes had difficulty making deci- sions regarding the appropriate level of care for callers by simply estimating their need for care by communicating via telephone. I had the opportunity to deepen my knowledge concerning telephone advice nursing in 2007, when I was accepted as a doctoral student to the Health Services Research Group at Uppsala University. This thesis, with its overall aim to investigate patient safety and communication within national telephone advice nursing in Swe- den, is the product of my search for knowledge and answers. The context of the research has been Swedish Health care Direct (SHD), which started in 2003 with three pilot sites; today, all of Sweden’s county councils except one have joined SHD. During 2011 SHD answered approx- imately 5.5 million calls, making it one of Sweden’s largest healthcare pro- viders (HCPs) today. A new HCP has hence been introduced and all citizens are advised to contact SHD when in need of care, yet knowledge regarding patient safety within this service is scarce. Within inpatient care, as much as 3% of all healthcare contacts are subject to medical errors, and studies have shown that communication is one of the most common causes of these errors (1-3). Based on this relationship, it is reasonable to assume that communica- tion has an impact on patient safety within telenursing as well as other healthcare settings. 9 Telephone advice nursing The definition of telephone advice nursing used in this thesis is: …prioritizing clients’ health problems according to their urgency, and advis- ing clients and making safe, effective and appropriate decisions, all by tele- phone. (Coleman (4) p. 227, 1997) Telephone advice nursing is used in many Western countries, including the UK, the US, Canada, Australia, Denmark and the Netherlands. These healthcare call centers’ services have quite similar aims, with telenurses giving callers’ individualized advice on a wide range of problems, from mi- nor disease to complex situations, with the assistance of a computerized de- cision support system (CDSS). The structure of telenurses’ work differs be- tween countries. At NHS Direct in the UK, calls are first answered by call handler who decides whether the call should be forwarded to a telenurse. Another difference between the Swedish and UK contexts is the fact that in Sweden the individual telenurse is responsible for his/her decisions and can be held personally responsible for any wrong decision, whilst in the UK the organization is held responsible. Since the introduction of the SHD in 2003, an increasing number of Swe- dish citizens have had access to SHD’s services. During 2011 about eight million of Sweden’s population of nine million had the possibility to call SHD for medical advice, and during this time SHD answered 5.5 million calls. The aim of this new HCP is to provide increased availability of quali- fied healthcare advice, increased safety for the public and increased efficien- cy of healthcare resources and, as mentioned, the service is quite similar to NHS Direct in the UK. SHD’s mission is to provide easily accessible, evi- dence-based healthcare advice day and night, year round, for the population regardless of geographic area (5). All county councils in Sweden have the opportunity to participate in the SHD network, and today 21 of 22 county councils have joined. Counties joining the network receive a total system solution: telephone equipment, electronic documentation and a CDSS (RGS 1177) (5). The telephone equipment can be connected to other councils in the network, allowing them to integrate during periods of high or low de- mand. In Sweden, SHD is staffed with approximately 1,100 registered nurses (RNs), telenurses, who independently triage callers’ needs for further care (6,7). There is no formal education for telenurses in Sweden today; only shorter university courses are available. Many telenurses are experienced and have different specialist educations such as primary care nursing or in- tensive care nursing, whilst others are relatively newly educated as RNs. A telenurse in Sweden can handle up to eight calls per hour (5), and these calls include a broad variation of age groups and medical conditions. The 10 telenurses can give a caller self-care advice or refer him/ her to another care provider (8). This demands that telenurses be well versed in healthcare or- ganization so that they can refer the care-seeker to an appropriate care pro- vider (9). Greenberg (10) describes how the telephone advice nursing pro- cess involves interpreting in a two-way process. Telenurses are to interpret callers’ data into healthcare information and translate this healthcare infor- mation into a language