Telephone Nursing: An Emerging Practice Area

INNOVATION IN LEADERSHIP 37 Telephone Nursing: An Emerging Practice Area Sharon Goodwin, RN(EC), BScN, MN Vice President, Quality, Care and Service VON Canada, North Bay, ON Abstract Governments across Canada and internationally are implementing nurse telephone advice services to their populations as a means to address healthcare access issues. This paper briefly reviews the international and Canadian history of telephone nursing services and outlines the research that has established the relative safety of these services to patients. The standards, competencies and decision systems that support safe tele-practice are reviewed. The paper focuses on the realities of this emerging nursing practice. A number of concerns related to the marriage of clinical practice and call centres are identified that require further dialogue, research and debate within the profession. The call centre environment can lead to a focus on efficiency measures, such as call length and quick turnaround to the next call, without evidence to ensure that these are safe or desirable standards. Quality of work life for staff in call centres is also raised as an issue that requires more research and dialogue. Other issues include cross-jurisdictional licensure, patient safety, privatization and the differing models of telephone nursing services that are being implemented in Canada. Introduction It s 2 a.m., and Nicole has been walking the floor for three hours with her infant daughter Emily, who has a fever and is crying. Nicole feels it is reassuring to be able to reach a nurse any time of the day or night. Janis, a registered nurse who works for a provincial telephone nursing service, listens empathetically to the

38 Nursing Leadership Volume 20 Number 4 2007 mom s concern. Janis has worked for telehealth for about eight months and is just becoming comfortable with the practice. She had an extensive orientation of two weeks in the classroom and then three months of preceptoring and mentoring from her senior nurse. The biggest challenge was learning how to navigate the software program with clinical guidelines while talking with patients. She enjoys the variety of calls, but she misses the face-to-face contact with patients that she was used to in more traditional nursing jobs. Janis is sitting in a call centre cubicle wearing a headset and with a computer screen in front of her; she is working a 10-hour shift that started at 9 p.m., and she has already handled 20 calls this shift. Janis talks, listens, reads, types and navigates the decision support software simultaneously while she takes Nicole through a number of symptom assessment questions from most urgent to least urgent. Janis has been coached by her supervisors to open the call with an open-ended question and then change to closed questions to control the call, accurately assess the symptoms and keep the call length to less than 10 minutes, on average. Based on her assessment, Janis recommends that Nicole seek care the next day, reassuring her that Emily is okay while teaching her how treat the fever until she seeks care. Nicole feels reassured and looks forward to getting some rest. Advances in phone and computer technology have spurred the development of telehealth services that transcend geographic boundaries. Among these, nursestaffed telephone advice services have been implemented in the United Kingdom, Australia, Sweden, the United States and Canada (Holmstrom and Dall Alba 2001; Knowles et al. 2002; Roland 2002; Stacey et al. 2003). There is a paucity of literature about telephone advice services from a nursing perspective. A literature search found that the majority of studies have focused on patient outcomes and cost effectiveness of services. This paper will provide background about the development of telephone advice services and then focus on issues in the emerging area of nursing tele-practice, where nursing research is needed. History and Development of Telephone Nursing Services Definitions Telehealth is defined by Picot (1998, as cited in National Initiative for Framework of Telehealth Guidelines [NIFTG] 2003: 18) as the use of information and communications technology to deliver health and health care services and information over large and small distances. The Canadian Nurses Association (2001: 1) defines nursing tele-practice as a nursing specific application of telehealth that includes all client centered forms of nursing practice. Telephone nursing or telenursing is a subset of nursing tele-practice that involves giving telephone advice, usually after performing a tele-triage assessment and often providing health information to callers. Tele-triage is the process of assessing the priority of urgency of

Telephone Nursing: An Emerging Practice Area 39 the patient s symptoms by telephone (Stacey et al. 2003). Typically, the public seeks health information or advice about symptoms from telephone advice services. History Giving telephone advice is not a new role for nurses and has occurred in such settings as emergency rooms, obstetrical units, crisis centres and public health units. The experience and expertise gained has informed the profession about the potential benefits and risks of telephone nursing and has led the way for broader provincial services. To make the practice as safe as possible, various authors developed guidelines to support practice, and by the 1980s, some guidelines were married with computer software for use in specialized telephone nursing centres. Specialized telephone nurse advice services began to proliferate in the United States in the 1980s and became widespread in the 1990s. These centres developed in response to escalating healthcare costs (Turner et al. 2002). US centres deliver these services to relatively small populations that are also served by hospitals or managed care organizations. The major objective is to prevent unnecessary use of emergency departments. In the United Kingdom, the National Health Service (NHS) Direct provides 24-hour-a-day telephone service to 50 million residents, and is therefore the largest whole-of-population approach to this type of practice (Knowles et al. 2002). Australia and Sweden have implemented services similar to that of the UK (Holmstrom and Dall Alba 2002; Roland 2002). In Canada, eight provinces and one territory have implemented around-the-clock nurse advice telephone lines that serve the entire population of their jurisdiction (Clinidata 2006; Newfoundland and Labrador Department of Health and Social Services 2006; Stacey et al. 2003). These services are publicly funded and administered in Alberta, Manitoba, Quebec, British Columbia and Saskatchewan (P. Nyhof, personal communication, June 20, 2005; Ministère de la Santé et des Services Sociaux 1999). In contrast, Ontario, New Brunswick, Newfoundland and Labrador and the Northwest Territories have contracted out service delivery to private companies (P. Nyhof, personal communication, June 20, 2005; Clinidata 2006). It is unclear how many local and regional services have been replaced by the provincial services. Very few rigorous studies of these services have been completed; most research has drawn conclusions limited by variability of interventions, settings and methodological quality (Stacey et al. 2003). The studies that have been done demonstrate reductions in physician office visits, but there is no clear evidence of reductions in emergency room visits (Stacey et al., 2003). There is no evidence that adverse

40 Nursing Leadership Volume 20 Number 4 2007 effects, such as subsequent hospitalizations or death, have been associated with tele-triage interventions (Stacey et al. 2003). None of the literature reviewed the issue of local vs. provincial services. Are there benefits to more locally based services, such as intimate knowledge of local resources versus the provincial approach? A Canadian study that audited the appropriateness of advice given by tele-triage nurses found that in 90% of audits the advice was judged appropriate and that tele-triage nurses were more likely to err on the side of caution (Hogenbirk and Pong 2004). Variability in the quality of the interaction with patients was noted in some of the research in the Canadian systematic review (Stacey et al. 2003). Driving Forces for Implementation of Telephone Nursing Services in Canada The benefits of telephone services for patients cannot be overlooked. Studies of economic impact have focused on the cost of reduced visits elsewhere in the system (Stacey et al. 2003). Research has not yet explored the economic impact for patients who can speak to a qualified healthcare practitioner by phone rather than having to obtain transportation, take time off from work and perhaps engage a babysitter. Patient satisfaction with these services is high, ranging from 55% to 90% (Stacey et al. 2003). Governments across Canada are responding to public concern about accessibility to health services. Telephone nurse advice services are a relatively inexpensive intervention for government in regions where an entire population of a provincial jurisdiction can be reached with one service. With fairly clear evidence that these programs are safe and have high levels of caller satisfaction, governments are not waiting for evidence of effectiveness to move ahead with implementation. Evaluations to date in Canada showed minimal evidence of clinical impact and a cost per call ranging from $10 to $27 (Stacey et al. 2003). The Practice of Telephone Nursing Standards and quality control in telephone nursing National telehealth standards have been recommended for organizations providing telehealth services (NIFTG 2003). The College of Nurses of Ontario (2005) has established standards for telephone practice addressing such issues as risks related to the lack of face-to-face contact, practising across borders, standardized protocols and high-quality practice settings. Strategies to monitor the quality of access to services for clients include elements of call centre measurements, such as response time for contact to the centre and call length (Stacey et al. 2003). In terms of quality indicators relating to the client, clinical outcomes such as referrals to physicians and emergency departments are tracked, as well as client incidents. Clients satisfaction rate, compliance and understanding are also measured (Stacey et al. 2003).

Telephone Nursing: An Emerging Practice Area 41 Although call times are measured and monitored closely in telephone nursing practice, benchmarks or best practices were not found in the literature search. One study, however, by Hoare et al. (1999), found a linear relationship between call length and the amount of documentation completed and cautioned that limiting call length may compromise quality of care. These researchers noted, the minimum data set for delivering good telephone nursing outcomes is unknown and requires more study (Hoare et al. 1999: 44). High-quality practice environments support an adequate length of time for each nurse client telephone interaction (CNO 2005: 11). Competencies required in telephone nursing The nurse working in telephone nursing practice needs strong clinical nursing knowledge, including application of the nursing process, highly refined communication and documentation skills and relevant knowledge of the technologies used in the practice (CNA 2001). The ability of the nurse to identify the worry in a mother s voice and impart not only clinically correct information but also compassion and caring is important to effective care. Excellent communication skills, critical thinking skills, computer literacy and superior assessment skills are key areas for success in the practice. Specific telehealth education is currently missing from almost all health professional education (NIFTG 2003). Given the proliferation of nursing tele-practice, there is a need to consider a telehealth curriculum in basic nursing programs and specialty education in this area. The curriculum should include advanced assessment, communication and counselling skills, health informatics, ethics and legal issues. Centennial College in Toronto is an early leader in this area, offering a oneyear certificate program in telehealth, which includes these areas in the curriculum (Centennial College n.d.). High-quality practice settings Tele-practice is a new area, and even seasoned nurses need adequate support to adjust to it. High-quality practice settings offer adequate orientation and mentoring programs to assist the nurse in moving from novice to expert in the area of tele-practice. Ongoing professional development opportunities and a learning environment are important for tele-practice nurses (CNO 2005). Decision support systems The CNA (2001) recommends the use of standardized decision protocols for telephone nursing practice. There are a number of software products available, such as those of McKesson, LVM systems, Healthline systems and others (Connections Magazine 2004). The clinical guidelines used in these systems are generally compiled by physicians and approved by medical advisers of the service.

42 Nursing Leadership Volume 20 Number 4 2007 Protocols are prescriptive in nature and tend to focus on determining the medical cause (Nauright et al. 1999). There is a need to ensure that these products are also reviewed through the lens of nursing practice. Nauright et al. (1999) discuss the relationship between protocol use and dispositions. Although protocols provide prompts to help nurses ask the right questions, these cannot account for the situational nuances in each unique patient encounter. A cookbook approach to nursing with protocol use must be avoided. The CNO (2005) emphasizes the importance of nurses applying their clinical judgment to each client care situation when using protocols. Issues in Tele-nursing Models of care The provincial telephone advice services available in Canada provide direct access to a registered nurse by the general public irrespective of their primary healthcare provider (Ministry of Health and Long-Term Care 2002; Stacey et al. 2003). Ontario has implemented a parallel telephone advice service through the Ontario Family Networks (OFN) for the rostered patients of physician groups. Registered nurses also deliver the OFN s after-hours telephone advisory service and are able to contact a physician on call for that practice group if required (Tamburri 2002). One could question why it was necessary to implement a tele-nursing service for the rostered patients of physicians when all residents in the province can access Telehealth Ontario. What are the costs and benefits of having two services in one province? In addition to this overlap, there are many public health advice lines and crisis lines available at the community level that can offer a service with more local flavour and knowledge. Research comparing the effectiveness of local versus provincewide services would add to the body of knowledge on telephone nursing practice. Privatization As Canada grapples with the role that the private sector should play in our publicly funded healthcare system, it is important to note that the private sector has already penetrated nursing tele-practice in three provinces and one territory. US software companies own most of the clinical guideline products. When private sector vendors are used for service delivery and clinical guideline development, sharing of information is restricted because of proprietary interests. The inability to share information openly is a definite limitation for an emerging area of practice. Work life for nursing staff A study of NHS Direct nurses (Knowles et al. 2002) found that while the majority of nurses enjoyed the work of tele-triage, a minority found it repetitive and monotonous. Research on call centres has been undertaken by Belt et al. (2000),

Telephone Nursing: An Emerging Practice Area 43 Knights and McCabe (1998) and Taylor and Bain (1999). These last researchers found that call centres as an employment choice [have] been explored as to whether they provide new opportunities for skill development and career progression or a highly routinized and de-valued area of work (Taylor and Bain 1999, cited in Knowles et al. 2002: 858). Criticism of call centres raises concern about their being sweatshops for customer service (Taylor and Bain 1999), partly because of the high level of scrutiny under which call centre staff practise (Incoming Calls Management Institute 2002). To ensure that clients have timely access to services, providers are required to attain certain service levels and abandonment rates. To achieve these targets the centre must have the right number of staff, at the right time and with the right skills, based on an accurate prediction of call volume and call length (Cleveland and Mayben 1999). These requirements lead to mandating call length and quick turnaround (Cleveland and Mayben 1999). As discussed earlier, there is no literature or research to support a best practice length of call. When nurses feel pressured to meet an average prescribed length of call they may hesitate to do simple things such as consult a colleague when unsure, or take the extra time to listen attentively to a client. Further exploration of how the focus on call length affects nurse satisfaction, interaction with patients and quality of care needs careful consideration by the nursing profession. Occupancy levels affect the psychological tenor of the work environment. Occupancy measures the amount of time the staff member is actually engaged in processing calls, excluding breaks, when working (Cleveland and Mayben 1999). Extended periods of high occupancy are stressful for staff, and when levels rise over 88% for any length of time, nurses begin to burn out. No industry standard can be set for occupancy level. However, chronic episodes of high occupancy, above 88%, reflect call centre management problems (Cleveland and Mayben 1999). Anyone monitoring these services should consider average occupancy levels as a critical measure reflecting the work life of staff. Call centres are known to have problems with high turnover of staff. Cleveland and Mayben (1999: 198) note that typical call centre industry turnover rates of 15% to 30% are unacceptable in today s environment. It often takes people 18 months to two years to become proficient. Anecdotal evidence indicates that turnover of nurses in call centres is well above rates in more traditional nursing environments. Given the current and projected nursing shortage, high turnover rates are not acceptable in healthcare. The Canadian Council on Health Services Accreditation (2004) identified absenteeism, turnover rates and staff satisfaction as key work life indicators. Research is required to determine how turnover rates within nursing call centres compare with those in more traditional areas of nurs-

44 Nursing Leadership Volume 20 Number 4 2007 ing practice and what best practices will promote optimal work environments. Patient safety Patient safety is a key concept under consideration by health organizations today and is a priority for all governments (Canadian Patient Safety Institute 2005). From the limited research that has been done, these services appear to reduce the number of immediate visits to physicians without causing adverse events (Stacey et al. 2003). Given the high-risk nature of this area of practice (CNO 2005), ongoing monitoring of patient safety indicators will be required. Cross-border licensure issues In nursing tele-practice, the caller could be from Alberta while the nurse might be located in Ontario. A number of organizations in Canada are working on standards for cross-jurisdictional healthcare because technology opens new ways to practise across borders (Jennett 2001). The Canadian Nurses Association (2001) recommends that the locus of accountability should be where the nurse is located. The College of Nurses of Ontario (2005), which has adopted the CNA s recommendation, warns nurses to be aware of the long arm statutes of some jurisdictions because they could be required to testify in a distant community (CNO 2005: 9). Conclusion Telephone nurse advice services are growing in the Canadian healthcare system and internationally. It appears that the Canadian system is more similar to those in the United Kingdom, Sweden and Australia in terms of its whole-of-population delivery model of telephone nursing than it is to US models, with the exception of the Ontario Family Networks after-hours telephone advice service. The marriage of clinical nursing services with call centres creates unique practice and work life challenges that have not been explored by the nursing profession. Quality of work life and the focus on efficiency measures in call centres are nursing issues that require further study and debate in the emerging area of tele-practice. As these services proliferate, the nursing profession must take an active role in defining this area of practice and in building the nursing-specific body of knowledge. Acknowledgements Sharon Goodwin is a J&J Wharton Fellow at the Wharton School of Business in Philadelphia. Correspondence may be directed to: Sharon Goodwin, VON Canada, 180 Shirreff Ave., Unit 210, North Bay., ON P1B 7K9; tel. 705-471-8981 or 705-495-6452; e-mail: dgoodwin7@cogeco.ca or sharon.goodwin@von.ca.

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