Telenurses face conflict between what is best for patients and what services are available

Nurses who provide telephone advice services have to balance the conflicting demands of providing appropriate medical advice and acting as a gatekeeper to limited healthcare services, according to a review in the March issue of the Journal of Advanced Nursing.

Canadian researchers reviewed 16 studies carried out over the last two decades, covering more than 700 nurses in the UK, Canada, the USA and Sweden. The studies included interviews, videotaped consultations, simulated calls and stimulated recall.

"Telenurses who took part in half of the studies expressed a conflict between what they thought was best for the caller and what healthcare services could provide" says lead author Dr Rebecca J Purc-Stephenson from the University of Alberta, Canada.

"They believed patients had a right to accurate handling of their problems, but were also conscious of the fact that doctors had a limited number of appointments available and that these needed to be kept free for urgent patients.

"Sometime telenurses advised callers who needed primary care to go to the emergency department because there was nowhere else to refer them to."

Dr Purc-Stephenson and co-author Dr Christine Thrasher, from the Faculty of Nursing at the University of Windsor in Ontario, maintain that telephone triage and advice services have substantially changed nursing practice.

"The first is that the nurses work in call-centre environments, rather than clinical settings, and the second is that they no longer have the opportunity to physically examine patients" explains Dr Purc-Stephenson.

Other key findings of the study include:

• The degree to which the telenurses used protocols varied across the studies, with some being restrained by decision-making software and others having more flexibility to use their clinical judgement.
  
• Telenurses often felt they had developed new communication skills including listening to verbal and non-verbal clues, like tone of voice, breathing, words and expressions used and general conversational tone.
  
• While some nurses felt that their clinical knowledge had been enhanced by working with colleagues, some raised concerns about retaining clinical skills. Although training was encouraged, heavy workloads and retention issues created barriers to ongoing training.
  
• Other nurses said that workloads left little time to interact with other telenurses and that the lack of feedback from the advice they gave was frustrating and had a negative impact on their job satisfaction.
  
• Some nurses felt stressed and exhausted by their heavy workloads and others were concerned that rushing calls could compromise quality of care. They also said that callers could become aggressive if they were kept waiting.
  
• In some cases telenurses felt uncomfortable making decisions over the telephone and considered worst-case scenarios in an attempt to reduce legal or professional consequences.
  
• One of the greatest challenges was to work out whether patients were exaggerating or playing down symptoms.

"Our review has revealed that telenurses face complex decision-making processes when they are dealing with calls, as they need to consider a range of factors" says Dr Purc-Stephenson. "Addressing some of these can help to remove barriers, but others can actually create barriers that prevent telenurses from adequately addressing their callers' needs.

"For example, the conflict between doing what is best for the patient and not overwhelming limited healthcare resources poses a real dilemma and in many cases there is no easy solution.

"There are a number of other implications for clinical practice and policy that need to be addressed.

"It is clear that the assessment skills used in face-to-face consultation are not directly transferable to the telephone and telenurses need specific training in telephone consultation, assessment and decision-making skills.

"Managers also need to address job demands, such as heavy workload, autonomy in decision-making, isolation and stress as these can have an impact on job satisfaction."