JAN ORIGINAL RESEARCH Real nursing? The development of telenursing Helen A. Snooks, Anne M. Williams, Lesley J. Griffiths, Julie Peconi, Jaynie Rance, Sharon Snelgrove, Srikant Sarangi, Paul Wainwright & Wai-Yee Cheung Accepted for publication 31 October 2007 Correspondence to H.A. Snooks: SNOOKS H.A., WILLIAMS A.M., GRIFFITHS L.J., PECONI J., RANCE J., e-mail: [email protected] SNELGROVE S., SARANGI S., WAINWRIGHT P. & CHEUNG W.-Y. (2008) Real nursing? The development of telenursing. Journal of Advanced Nursing 61(6), Helen A. Snooks PhD 631–640 Professor of Health Services Research doi: 10.1111/j.1365-2648.2007.04546.x Centre for Health Information, Research and Evaluation (CHIRAL), Swansea University, UK Abstract Title. Real nursing? The development of telenursing Anne M. Williams PhD RN Aim. This paper is a report of a study to understand the impact of telenursing from Professor of Nursing Research the perspective of nurses involved in its provision, and in more traditional roles. Department of Nursing, Health and Social Background. Nurse-led telephone helplines have recently been introduced across Care Research Centre, Cardiff University, UK 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 Lesley J. Griffiths BSc PhD Professor of Health Policy Direct (National Health Service Direct) Wales telephone service (n = 111). Ninety- School of Health Science, Swansea two completed questionnaires were returned (response rate 83 per cent). Two focus University, UK groups were conducted: one with telephone service nurses (n = 8) and one with other nurses (n = 5). The data were collected in 2002. Julie Peconi BSc Findings. Respondents represented a highly educated workforce from a range of Research Officer healthcare specialties. They reported that they joined the telephone service for Centre for Health Information, Research and improved salary and flexible working. Two-thirds reported improved job satisfac- Evaluation (CHIRAL), Swansea University, tion. All focus group participants reported that the development of nursing skills UK was affected by the use of decision support software and the remote nature of the Jaynie Rance PhD C Psychol consultation. Participants reported opportunities for skill development, although the Lecturer role could be stressful. All agreed that the service was popular with callers, but the School of Health Science, Swansea nurses from outside raised concerns about whether telenursing was ‘real’ nursing University, UK and about the evidence base for the service and access by disadvantaged groups. Conclusion. Differences between the groups reflect policy tensions between the Sharon Snelgrove BSc MPhil RN need to develop new nursing skills, including the use of technology, to improve Lecturer School of Health Science, Swansea efficiency and recognition of the worth of hands-on nursing. These tensions must be University, UK addressed for the telephone service to function as part of an integrated healthcare system. Srikant Sarangi MA MLitt PhD Professor in Language and Communication Keywords: focus groups, nurse roles, policy, questionnaires, telenursing, technology Cardiff School of English, Communication and Philosophy, Cardiff, UK Introduction The NHS 24-hour nurse-led telephone-based health advice and information helpline, commonly known as NHSD, was launched in England in 1998 (Department of continued on page 2 Health 1997), and in Wales in 2000 (Gregory & Kennedy 1999). Evidence shows Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd 631 H.A. Snooks et al. Paul Wainwright MS PhD RN that educational interventions which enhance people’s sense of self-efficacy can Professor of Nursing reduce the demand for medical intervention leading to cost savings (Coulter 2003), Faculty of Health and Social Care Sciences, seen as integral to the modernization of the NHS (Wanless 2002). Modernization Kingston University and St George’s, involves the reconfiguration of professional roles, particularly at the boundary University of London, UK between medicine and nursing. At this boundary, as previous work has shown, Wai-Yee Cheung PhD substitution of nurses for doctors and the creation of new roles form part of a Senior Lecturer in Medical Statistics workforce reconfiguration strategy. This strategy has been used in the united Centre for Health Information, Research kingdom (UK) and internationally to meet changing patient expectations, rising costs and Evaluation (CHIRAL), Swansea and skills shortages (Sibbald et al. 2004, Hyde et al. 2005). From this perspective University, UK NHSD, insofar as it may redirect patients from doctors to nurses, can be seen as part of a wider effort to control access to care (Charles-Jones et al. 2003a) and as having consequences for patients, doctors and nurses. ambivalent about telephone work, with some expressing Background enhanced levels of satisfaction and others concerned about A telephone advice service represents a break with traditional the lack of what they perceive to be ‘hands-on nursing’ and forms of delivering nursing care, and is increasingly being the ‘monotony’ of working in a call centre (Knowles et al. used in a range of developed countries (Lattimer & George 2002). The impact of the recruitment of nurses by NHSD on 1996), from Australia (Turner et al. 2002) and New Zealand other services has been assessed (Morrell et al. 2002). (St George & Cullen 2001), through Denmark (Christensen However, the views of nurses in the wider NHS workforce & Olsen 1998), Sweden (Marklund & Bengtsson 1989) and about the impact of NHSD have not been researched in any the UK (Department of Health 1997), to Canada (Lafrance & systematic manner. The study reported here was the first Leduc 2002) and the United States of America (Barber et al. opportunity to compare the views of two groups of nurses, 2000). Telenursing has been explored in a preliminary way in working within and outside of the service, about the impact general practice (Charles-Jones et al. 2003b) and community of NHSD Wales (NHSDW). nursing (Wilson & Williams 2000). However, there is still much work to be performed to understand telephone-based The study clinical decision-making processes and nursing practice issues. Pettinari and Jessop (2001) explored the impact of Aim NHSD on nursing, and looked at how the absence of visibility is managed through the development of assessment The aim of the study was to understand the impact of skills based on professional knowledge and experience, telenursing from the point of view of nurses involved in its compensating for not being able to see patients. They provision, and those in more traditional roles. identified three broad areas in which nurses anticipate and manage absence of co-presence: (1) gathering information, Design (2) delivering information, advice and reassurance (3) build- ing trust and rapport. Central to the reasoning process is The work was conducted in two phases. Phase 1, a survey of ‘picture building’, in which both the person and the pathol- nurses working within NHSDW, focused on recruitment, ogy are visualized (Edwards 1998). To do this, nurses elicit reasons for joining the service and job satisfaction. The focus the presence of physical signs and symptoms by asking groups undertaken in Phase 2 concentrated on issues arising specific questions about, for example, the presence of a rash from the survey related to the development of nursing or a level of pain, but they also try to build a picture of the practice and clinical decision-making. client as a person and their environment. The nurse is dependent on the quality and accuracy of the information Participants provided, which requires that the caller gives the information in a way that allows the nurse to understand and visualize the All NHSDW nurse advisors were invited to participate in the caller’s situation. study by responding to the questionnaire survey and by Outcomes of assessments made over the telephone by joining a focus group discussion. In addition, a purposive nurses vary (O’Cathain et al. 2003, 2004), and nurses feel sample of nurses working outside NHSD was invited to 632 Ó 2007 The Authors. Journal compilation Ó 2007 Blackwell Publishing Ltd JAN: ORIGINAL RESEARCH Development of telenursing participate through a second focus group. Full details of Data analysis respondents are given below. The survey data were coded and analysed using an Access database and Statistical Package for the Social Sciences Data collection (SPSS) Version 11 for Windows (SPSS Inc., Chicago, IL, Phase 1 NHSDW nurse survey USA). Comparisons were made with national data using the The questionnaire used to survey nurses working for chi-squared test for differences in proportions. Responses to NHSDW was closely based on that originally developed for the open-ended questions were thematically analysed. Focus use with NHSD nurses in England (Knowles et al. 2002). The group transcripts were analysed inductively to identify three-page questionnaire, which included both structured themes, which were then discussed, amended and agreed items and open-ended questions, was distributed to every among team members to ensure that key themes or points nurse advisor working in the three NHSDW sites in Wales via had not been overlooked or misinterpreted. team managers and then through the internal mail system in October 2002. Completed questionnaires were returned in Results reply-paid envelopes direct to the research