Main Summary
This interview study, describing RN views on telephone nursing work with callers to the PHCC, reveals that RNs view their daily work as a continuous challenge and that supporting structures are insufficient. The themes challenge and support were built on five categories. These were: the triage, assessment over the phone and to manage expectations, evidence-based knowledge and professional collaboration. In the telephone triage, RNs had to differentiate urgent problems from what could be handled through self-care advice, always with a fear of missing something serious. This was expressed with the vulnerability of small children into mind. RNs also acknowledged the importance of self-advice and comfort for callers. They highlighted the need to explore both the medical problem and who the caller was as a person, heavily relying only of what they heard. Furthermore, RNs expressed having to cope with patient expectations, which were especially challenging when communicating with patients with other cultural backgrounds. The RNs also described their lack of enough possibilities to keep up with evidence-based knowledge. DST and guidelines were only partly known and used, and CME was not always prioritized. Moreover, professional collaboration was described as unstructured with deficient local routines, feedback from the GPs and support from colleagues.
Recent studies of RN triage during office hours in primary care confirmed a decrease in face-to-face contacts with the GPs, but not a decrease in total clinical contacts (18). The dual roles of the RN as care providers and gatekeepers is a challenge that is evident at the Swedish PHCCs (19). In Swedish primary care, telephone triage has long been an obligatory step to get a GP appointment. The available slots for booking are scarce, appointments are fewer and consultation times longer than in most European countries (20). The RNs must balance the risk of missing a serious disease against taking responsibility also for the GP workload.
When the RNs assessed the patient’s problem as self-health they tried to give self-care advice to avoid unnecessary GP consultations and prescriptions for antibiotics. This is in line with earlier studies, which report that telephone RNs want to support, coach and educate the callers (21). When dealing with children the RNs said that they lowered their threshold for allowing GP appointments. Second hand consultations, which are common in paediatric health calls (5), entail further difficulties in assessing the situation (22). Comforting parents was described as important as curing, well in line with earlier studies (21, 23).
RN telephone triage has probably made a crucial contribution to the decrease the antibiotics prescriptions in Sweden (6, 24) and is in line with the principle in Swedish healthcare that self-healing problems should be managed by self-advice from RNs in order to empower the patient and reduce healthcare utilisation. This has been possible in a healthcare system that is financed from taxes, with well-educated RNs and salary paid GPs. However, the RNs described the difficulties for people from other cultural backgrounds to adapt to the Swedish system. Surprisingly enough, no one mentioned the use of patient information on the national website 1177 (26) or from the Public Health Agency of Sweden (25), which is available in several languages.
The challenges the RNs reported that they experienced in telephone triage regarding the need to assess both who the calling person is and the problem, due to relying only on what was heard, and how these two tasks are interrelated in an intricate way, is in line with earlier studies (27). Thus, training and communication skills seem just as important as knowledge of the different guidelines for RTI (28). The importance of communication skill is argued by several studies where communication training of GPs decreased antibiotics prescriptions for patients with RTI (29). In order to respond to the expressed RN needs for educational efforts on telephone triage, CME activities could integrate communication skill with medical knowledge.
Likewise, medical knowledge seems just as important as the communication skills. The RNs described how they thought of different diagnoses, especially concerning callers with a cough. This is in contrast to earlier studies from interviews with RNs working at Swedish Healthcare Direct (21). Perhaps this difference is due to cooperation with GPs at the PHCCs who mostly explain symptoms in terms of one diagnosis and other diagnoses.
Updated evidence knowledge is crucial for RN assessment of the callers’ problems. The RN use of DST and guidelines was inconsistent among the interviewed RNs The national guidelines are implemented through out-reach visits in the health centres, both to GPs and RNs. However, the guidelines are developed by physicians and focused on diagnosis and treatment. Thus, the guidelines seldom elaborate on factors for telephone triage. The modest participation of RNs in creating the guidelines is astounding in a country with long traditions of RN led telephone triage in primary healthcare, and where RN telephone triage is mostly a prerequisite for getting a GP appointment. The national DST is designed for RN triage and is regularly updated to correspond to current guidelines. A more consistent use of DST thus might facilitate shared PHCC routines and teamwork between GPs and RNs.
Most RNs lacked systematic CME at the PHCC for common infections, such as RTI. Instead, when offered, the RNs often prioritized CME in their special assignments. In contrast to RNs’ work at Swedish Healthcare Direct, the interviewed nurses had mostly chosen to work at the PHCC because of the possibility to work face-to-face with their own patients. Telephone triage was not something they had chosen as their main duty, but rather as an imposed compulsion. Thus, CME for these common problems had lower priority, both at the organizational and the individual level, at the time of the study. It seems that knowledge and competence regarding the most common problems in telephone triage, where RN self-advice is crucial, is taken for granted. Thus, a proper introduction and preparatory training when the RNs are employed at a PHCC, seems to be an urgent measure that should be established.
All RNs participating in the study asked for feedback on their telephone nursing work from the GPs, but no one had experienced this in a systematic way. Several reviews emphasize well-functioning inter professional cooperation as the key to knowledge translation and evidence-based practice (30, 31). In many countries, RNs and GPs work together but the role and function of RN work varies from one country to another (32). Close cooperation between RNs and GPs can facilitate feedback. This is more easily organised at PHCCs, where both professions work together, in contrast to Swedish Healthcare Direct, which only employs RNs. A fruitful collaboration builds on mutual professional respect and trust, based on professional competence (33, 34). In this respect, the prerequisites are good in Sweden, which has well-educated RNs. However, this study demonstrates that the RNs had to ask for feedback in order to receive this. Lack of response on performed work may increase feelings of insufficiency and abandonment regarding their work.
The RNs not only wanted feedback from the GPs, but also asked for possibilities of support from colleagues and time for discussions within their own profession. These activities could decrease occupational stress and reduce the feeling of being alone in the telephone triage (35). At a PHCC with an open work climate, this could be rather easily organised by the RN professionals themselves.
RN telephone triage in the Swedish primary healthcare has been crucial and well established for many years, however rarely researched. This is one of a few studies exploring telephone triage within PHCCs both internationally and in Sweden. It is thus a valuable contribution to the research on telephone triage out-of-hours (10). Experiences may therefore also be important to other countries when establishing a similar organisation, even though differences in healthcare systems must be taken into account.
The interviews were carried out as part of an earlier study where the aim was to explore factors important for antibiotics prescription (6). Thus, the focus did not include the wider perspective on the RN work in telephone-like workloads, work environment and the overall experience of the work in telephone triage. There was no RN in the initial research group and perhaps the interview guide had been different if this was the case. Moreover, the different interviewers had different pre-understandings of the work in primary care, which may have had a negative impact on the communication.
The purpose of qualitative content analysis is to acquire both knowledge and an understanding of the phenomenon studied (15). As we set out to identify variations with regard to differences and similarities of a text, content analysis with an inductive approach was selected. Graneheim and Lundman highlight the importance of communication for the interpretation as one of the characteristics of content analysis (15). Texts based on interviews are formulated through interaction between the respondent and the person conducting the interview. The analysis is an unprejudiced description of the variations by identifying differences and similarities in the text, and they are expressed in categories and themes where context is very essential.