Aim: To describe newly graduated district nurses' experiences of providing healthcare advice via the telephone at healthcare centers. Methods: Descriptive design with an inductive approach. Qualitative interviews and content analysis. Ten newly graduated district nurses were interviewed 2013 in Sweden. Results: Newly graduated district nurses' experiences were as wanting to do the right thing by being available to the caller and wanting to avoid misdiagnosing; thus, doing the right thing by the caller but also to protecting oneself. District nurses need and use the support of computers, colleagues and employers. Their work is influenced by their introduction, their ability to feel job satisfaction and organizational conditions. Personal prerequisites are needed. Conclusion Newly graduated district nurses need continuous training, support, feedback, and time to learn and be time-effective. A good introduction and support from their employers make it easier to learn. The introduction should be based on the person rather than what the business has to offer.
Telephone advice is a growing and complex component of nurses’ work in Australian, New Zealand , USA , and many Western countries . Even so, there is limited research regarding newly graduated district nurses (DN) providing telephone advice. DN’ telephone includes triage, advice, support, training, referrals, information and coordination .
There is a growing base of evidence for the effectiveness of telephone triage , and can impact the nursing shortage, providing care to patients, regardless of geographic location. Providing telephone advice is considered rewarding because it is varied and instructive. All calls and callers are unique, which is stimulating and challenging . The pace of the work, together with the ability to control their work and make their own decisions is considered fun. Telephone advice are also demanding [1-11]. Telephone advice is demanding because calls must be kept short, callers are not visible, nurses have to work with second-hand information, they are afraid of misunderstanding, and there can be conflicting demands. Non-visual communication makes it difficult to assess a caller’s condition and reliability. Forty-seven percent of callers are relatives, usually calling about a child under the age of 18 . Misunderstandings can lead to errors of judgment, jeopardize patient safety, patient’s deaths , and the loss of nursing license .
The limited number of general practitioner (GP) appointments available must be prioritized for the healthcare seekers who need them the most . Acting as both a caregiver and a gatekeeper and keeping conversations short because of workload were experienced as conflicting demands . Telephone advice was further hampered by inadequate support from management, poor working conditions, and monotony [8, 9].
Counseling support (RGS) is a computerized software that supports DN’ telephone advice. RGS can also hinder telephone advice , since it not considered user-friendly, and medical terms have to be explained to callers so they can understand. Updating symptoms, diagnoses and self-treatment in RGS can also fail. RGS can facilitate telephone advice; decision-making can be faster and easier. RGS can also be used to improve nurses’ credibility in the eyes of care seekers who may demand a GP appointment even though the nurses does not consider it necessary .
In summary, there has been research into nurses providing telephone advice. However, there is limited research into newly graduated DN and the telephone advice they give at healthcare centers. Describing newly graduated DN’ experiences of telephone advice can contribute to understanding what they need to provide safe advice and achieve safe patient care. The aim of this study was to describe newly graduated DN' experiences of providing healthcare advice via the telephone at healthcare centers.
The design was descriptive with an inductive approach. Individual interviews were used and data were analyzed using qualitative content analysis [12, 13]. The study was performed October 2013 in Sweden and followed the ethical principles for medical research involving human .
The sample was carried out first using a snowball sample which generated five DN . In order to recruit more participants, a strategic selection was applied to a class list of DN who graduated in 2012; this provided five DN. A total of 10 newly graduated DN at two health centers were included in the study. The DN were contacted by phone and given verbal information about the study. Health center operations managers who received written information about the study gave their consent.
The term ‘newly graduated’ refers to DN who completed their training in specialist nursing for primary healthcare less than a year ago. In Sweden, this training usually only includes a small amount of telephone advice training, less than a week. The DN had less than one year’s experience of providing telephone advice. All participants were women with a mean age of 40 (min - max = 28-48). They had an average of six months (min - max = 1 - 10) professional experience as DN. They had provided telephone advice on average 18 hours a week (min - max = 5-25). Three of them had completed a two-day training course in telephone advice.
The DN decided when they would be interviewed and that the interviews would be conducted at their workplaces. They received additional written information and gave their informed consent before the interviews began. Background data were collected regarding their age, how long they had worked as a DN, how many hours a week they spent providing telephone advice, and whether they had had any training in providing telephone advice. Semi-structured interviews were conducted .
The interviews began with the opening question, “Can you tell us about your experiences as a newly graduated DN providing telephone advice at a healthcare center?” After this, follow-up questions were asked based on certain subject areas. A) “What resources do you use and how do you use them when providing telephone advice?” B) “What do you feel is positive about telephone advice?” C) “What difficulties does providing telephone advice entail?” D) “What would you like to change about telephone advice?” E) “Can you describe your introduction?” To conclude, follow-up questions were asked as needed. a) “Have I understood you correctly?” b) “Is there anything else you want to add?” The first interview served as a test interview in order to check logistics and the relevance of the questions . Since the questions worked well, the test interview was included with the data collected. The interviews took 30-40 minutes and were recorded.
Before giving their informed consent, DN were provided with information about the study. They were informed about the voluntary participation and that they at any time could end the interview without giving any reason. They were guaranteed confidentiality and anonymous presentation of results. Ethics committee approval was obtained from an University.
The interviews were analyzed using qualitative content analysis . The analysis began with the interviews being transcribed and then read in their entirety several times to get an overview of the content. Meaning units describing the newly graduated DN' experiences of providing telephone advice at a health center were identified and condensed. Thereafter, these condensed meaning units were abstracted to codes. The analysis went on to compare the content of the different codes to discern similarities and differences. Codes with similar content were grouped together in sub-categories. The content of the sub-categories was compared and abstracted into categories. The authors continuously discussed the analysis process to achieve consensus. Table 1 shows examples of the analysis process.
|Meaning unit||Condensed meaning unit||Code||Sub-category||Category|
|I think it's good there (sitting alone in the office), it's quiet and comfortable for your ears. I have reflected so much of it, I know there is room for more than one person.||It is good to sit on one’s own in the office; it's quiet and comfortable for your ears.||It's quiet and enjoyable to sit on one’s own||Organizational conditions||Requires certain prerequisites|
The results of the newly graduated DN' experiences of providing telephone advice at healthcare centers are presented in categories, see Table 2.
|Always being available to the healthcare seeker||Wants to be available to the healthcare seeker||Wanting to do the right thing|
|Not daring to ask the healthcare seeker to wait because of fear||Wants to avoid making the wrong assessments|
|Using the internet||Support from computer systems||Needing and using support|
|Working on your own feels lonely. Wanting to work with others in the same office when you are new||Support from colleagues|
|Being passed through to the number of the healthcare seekers per hour||Support from employer|
|Gaining experience over time||Learning||Being in a learning process|
|Being given a shorter introduction because of prior clinical training||Introduction|
|Helping healthcare seekers||Feeling work satisfaction||Work satisfaction|
|Being stressed because the "allowed" length of time for a call is inadequate||Feeling work dissatisfaction|
|Using one's intuition||Personal prerequisites||Prerequisites are required|
|Wanting more GP appointments||Organizational prerequisites|
The DN experienced wanting to do the right thing by always needing to be accessible to the caller and wanted to avoid incorrect assessments, both to do right by the caller, but also to protect themselves.
"It's the top priority, the phone is the most important thing in a healthcare center / ... / Simply because you have to be available to the patient somehow. You have to always be able to reach the healthcare center, yes, because it is a very important part."
Wanting to do the right thing, such as avoiding incorrect assessments, included the complexity of making accurate decisions and prioritizing. It was difficult for them to assess care needs based on second-hand information and not being able to see or examine the patient. This difficulty could apply to specific patient groups, such as children who cannot always express how they feel even if their parents are able to interpret their children well. It could also apply to callers who had difficulties expressing themselves in Swedish and to older callers. Talking to people was described as "an art". Avoiding incorrect assessments also included experiencing how important it was to listen to what the caller was saying and asking the right questions. These questions needed to be open so as to avoid focusing on a specific diagnosis early in the conversation; the questions also needed to be repeated. The right questions had to be asked to avoid missing information, to understand the caller’s care needs, to reconnect to the caller, and to get an overall picture of the caller's situation. To avoid incorrect assessments, the DN tried to speak slowly and simplify their language. This was particularly applicable for children whom the DN had little experience of diagnosing.
"You often make appointments for children ... actually. At the time, it seems ... it's, they ... well, because you never know. And you feel like, but God ... what if I miss something when it comes to this child ... that would be terrible. Because children are not like adults either, when it comes to ... everything ... symptoms ... and such. "
The newly graduated DN wanted to do the right thing for themselves by documenting that their assessment was conducted based on the symptoms the caller stated in the call. They did this to ensure they could not be blamed if something were to happen to the care seeker. Doing the right thing for oneself also entailed urging the caller to take ownership and call back if there was no improvement or if things got worse.
"You want to safeguard yourself from ... from an assessment. You have to, you have to write it down so that you can see that this assessment was done here and now based on the symptoms that the patient described."
The DN needed and used support from computer systems, colleagues and employers. Computer system support included RGS, the internet and templates. RGS support was considered necessary and was used for guidance when assessing severe symptoms, for tips on questions to ask, providing self-care advice, and making consistent assessments for the same illnesses. However, it was difficult to completely comply with RGS because of a lack of time. It was difficult to find time to ask all of its questions and to offer GP appointments according to its recommendations. In addition, it was difficult to assess how urgent a matter was because the symptoms described in RGS were taken out of context.
"I think it (RGS) is a great tool ... for more difficult ... symptoms ... which are a bit vaguer. Which can be ... which can cover a lot, dizziness and such. That’s when I use it. But I think it's hard to follow it all the way, or you don’t have enough time to ask all the questions there. And you can’t follow it ... there isn’t ... because there aren’t enough GP appointments available as fast as the support system wants. So you can use it as a guide in your assessment."
Internet support included Google and 1177, the National Telephone Network Decision Support Named Advice Support System . The latter includes data on self-care advice and help to prioritize emergencies. Template support consisted of questions to ask in cases of recurring symptoms. Needing and using support from colleagues was described as having someone to consult with and, therefore, sharing an office could be good for feeling confident at work.
"I think we were a lot of help to each other in the beginning because we ask each other questions... Because you have a lot of questions, and I’ll never forget the first calls... because it's like... oh, right ... okay ... I think it's this ... but ... I’ll go and ask. "
The newly graduated DN needed their employers to show that they understood that it would take time to get used to the role of telephone counselor. Employer support also included the opportunity for them to influence telephone advice such as having longer to talk.
The DN had experienced learning and being introduced as newly employed. Learning took time and was described as a continuous process that led to a confident professional role. It took time to learn the rules, routines, and local and national guidance as these are extensive and complex. They found that providing telephone advice required them to know a little about a lot of things as they dealt with people of all ages.
"You can’t get it all in one package when you start; it's probably a learning process that when you stop here ... well, then you know the next time that, right then ... but then I think it's a learning process I guess. You can count on it. It takes a while before you have enough knowledge for the job, so to speak. You ... you want a little more flesh on the bones, but you understand that you have to practice."
The newly graduated DN felt that their introductions contained a lot of information in a short space of time and that made it easy to forget or miss something.
"I might have been given information but there is so much. It's like 14 days, I got so much information and so here, so you might have forgotten something or missed something so ... You know, I have realized that, because I have been forced to ask again or, if I haven’t been given that information, I don’t actually know because it was right at the beginning."
What facilitated their introduction were previous clinical placements at their current workplaces. But these could also lead to shorter introductions because employers saw the placements as introductions. Other factors that contributed to poorer and shorter introductions were vacation time and sick leave. A short introduction could mean that learning occurred when problems had already happened, but being "thrown" in that way into something new and strange could feel terrible. Sitting next to colleagues, listening and learning from their advice and feedback was better. Learning by trial and error was also positive.
The DN experienced both work satisfaction and work dissatisfaction. Experiencing work satisfaction was described in the context of contact with healthcare seekers and helping them.
"It's exciting, because it's ... you never know what you’ll get on the phone. Could be anything from ... yes ... it can be anything from foreign families who call and you can’t hear what they are saying because of the language and you have to try to figure it out. Or it could be English-speaking healthcare seeker callers, or healthcare seekers who are embarrassed about calling, who find it hard, some things can be very difficult. So it's a mix, and I think that’s quite exciting, all these different healthcare seekers, and types of patient, on the phone."
Helping healthcare seekers meant answering questions and finding a solution so that the healthcare seekers were satisfied and appreciative. Getting feedback from the healthcare seekers about previous assessments felt good.
"Most of the time I make the right assessment, and I think it's important to listen to the caller’s story. I think that ... you really have to listen to the caller ... like what is the patient saying ... and afterwards you are told that you made the right assessment, then ... then it's great, it's very positive."
The DN experienced work dissatisfaction when they could not help healthcare seekers or calls were too short. Not being able to help patients was described as it being difficult being yelled at by callers, but there were also unpleasant conversations and having to discuss things that the newly graduated DN' could not influence such as the shortage of GP. Not having enough time to talk could be stressful. It was easy to fall behind and calls waiting in the queue were stressful. This meant that DN felt compelled to cut short calls and healthcare seekers were asked to book a new call.
"I struggle with time ... against time, you could say ... every call's booked for five or six minutes, depending on which healthcare center you are at ... and a call rarely takes five minutes including what you have to document."
The DN' personal and organizational conditions affected their work. Their personal conditions were described as being confident, alert, and using their intuition to make the right assessments, and not always following RGS. They needed the ability to perform under time pressure, like being able to take more calls in less time when, for example, there was a staff shortage or a lot of people were calling at the same time.
When it came to training, the DN wanted call templates to use in difficult conversations so as not to misunderstand the healthcare seeker. They also wanted more training in telephone advice to make correct assessments and understand how RGS can be used. Having more GP appointments could facilitate prioritising fairly. It was difficult to provide GP appointments within a reasonable time, and it was hard to dissuade those who were not in need of an appointment.
"It is difficult, a lot of them want to see a doctor and get antibiotics and you have to try to explain that it can be either a virus or bacteria, and usually it's a cold virus and then antibiotics won’t help, but I know it's really hard. Many people want ... they want to come and have it checked out ... so they want to come and check that it’s not something dangerous, so that it doesn’t get worse. But you try to give them some self-care advice ... it’s really well documented in RGS and, in principle, you can just read it out, but ... yes, people usually know what they want, yeah. They have decided from the beginning that they want an appointment - that’s when it is difficult, I think. You can hear it straight away on the phone, ‘I want an appointment’. Some I manage to give advice to, but I think that’s quite rare.”
DN working with experienced colleagues facilitated providing telephone advice for the newly graduated DN. They considered it an efficient use of time and they felt calmer than when they worked on their own.
The DN wanted to be available to callers. This is in line with previous research that shows that nurses at healthcare centers can be reached during opening hours . This study describes how the newly graduated DN felt that telephone advice was the most important task at a healthcare center. This has not been described in earlier research.
The DN wanted to do the right thing for the caller and avoid incorrect assessments. This was complicated by language difficulties and not being able to see the caller. This is consistent with previous studies that showed that it was hard to assess using second-hand information and without seeing the caller . This result is in line with earlier studies  who argue that misunderstandings can lead to incorrect assessments, jeopardize patient safety, and deaths. Therefore, continuing training is of importance, since advanced practice nurses can reduce the risk of malpractice in the delivery of telehealth . However, the training of the telephone adviser, their level of questioning, and the quality of their advice all varied widely .
To avoid questions leading at a specific diagnosis early in the call, DN in this study strove to ask open questions. This has not been described in earlier research. The DN in this study described that they documented their assessments in the medical records in case they were questioned should something to happen to the caller. This approach could be interpreted as a fear of being reported for incorrect assessments .
The DN described how they used the internet and query templates to help and guide in assessments. Holmström (2007) also mentions that colleagues were used to help in assessments. The results were also in line with Ledin et al. , who argued that RGS was used as a memory support. In this study, RGS was described as not being user-friendly and being difficult to comply with fully because of the lack of GP appointments. This has been confirmed by Ernesäter et al.  and Ledin et al. . Based on this, the use of RGS could be facilitated by clear information as to how it is structured which, in turn, could lead to consistent assessments.
The results showed that consulting colleagues contributed to the DN’ feelings of confidence. This is consistent with Ledin et al. , who reported that colleagues were used to help in assessments . The DN experienced their employers' support in the form of understanding that it takes time to adjust to the professional role of telephone counselor. Employers gave the newly graduated DN the opportunity to influence their work situation. This has not been described in previous research.
It took the DN time to learn about telephone advice, and they described it as continuous learning. They described knowing about telephone advice as knowing a little about a lot of things. Earlier research has confirmed the results of this study, that telephone advice is varied and instructive. It was both challenging and challenging to use all of their skills while continuing to search for new knowledge. However, previous research has not described that it takes time to learn.
The DN felt that their contact with patients during telephone conversations was fun, exciting, and challenging. It felt good to them to help healthcare seekers so that felt satisfied and appreciative. These results are consistent with previous research . The DN in this study appreciated getting feedback from those who had sought help previously. This is consistent with Röing et al. (2013), who point out that telephone advice is hampered by a lack of feedback.
Demands for short calls and call queues could be stressful and lead to the DN feeling compelled to cut short calls because of lack of time. There is no previous research confirming that calls have to be kept short because of workload . Short calls made it difficult to respond fully to health issues . Based on this, one may ask if newly graduated DN were stressed because of limited call time, the need to consult others, or a lack of experience. However, stress is shown to be a factor contributing to errors that have led to malpractice claims in telenursing  The newly graduated DN felt that it was difficult to provide GP appointments within a reasonable length of time. They felt that access to more GP appointments could help them achieve fairer assessments. There is no previous research confirming that the lack of GP appointments hampers correct prioritization or that the care seeker receives the wrong level of care. This study’s results show that many seeking help wanted a GP appointment and that it could be difficult to dissuade those who did not really need one. Previous research has confirmed that using RGS can help care seekers who are demanding a GP appointment to accept a RN’ advice that an appointment is not necessary from a medical viewpoint .
To achieve trustworthiness, the analysis process were discussed to reach agreement, and was also discussed with colleagues at several seminars [12, 13]. The intention was to describe clearly the method and results with descriptive quotations. Using snowball sampling may have had an influence by recommending individuals who, for example, have strong opinions about the phenomenon being investigated. Nevertheless, none of the participants was perceived as standing out in any way. The Swedish context and the sample size was a threat to transferability. However, other nurses working with telephone advice and newly graduated DN might identify with the results. Likewise, as in the study by Röing and Holmström , if the difficulties in recruiting participants for this study are any indication, reaching out to healthcare providers who remain silent may be the greatest challenge.
The newly graduated DN believe that telephone advice is the most important task at a healthcare center. They want to do the right thing and are afraid of assessing healthcare seekers incorrectly. Recommendations for practice are that newly graduated DN need to learn continuously, receive support and feedback, and be given time to learn. Employers need to support and facilitate introductions learning the new task of providing telephone advice. Introductions to telephone advice should be based on the newly graduated DN' needs and not simply on what the employer has to offer. It can be helpful to work closely with colleagues.
We are grateful to those who so willingly agreed to participate in this study, and to language reviser Moira Dunne.
No conflict of interest has been declared by the authors.
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