Two themes and five categories emerged from the data regarding describing RNs’ views of telephone nursing work with callers contacting PHCCs about respiratory tract infections. These are presented in Table 3. RN informant quotes are presented in italics and the interview numbers are presented in brackets.
During the category analysis, the theme challenges emerged from the three categories: Communicate for optimal patient information, Differentiate harmless from severe problems, Cope with caller expectations. These all dealt with what RNs found difficult and challenging in their telephone nursing professional work at PHCCs. The three categories under this theme are further presented below.
Communicate for optimal patient information
Communication in calls was raised by the interviewed RNs as a difficult task. The lack of visual information and the need to rely solely on verbal caller information increased RNs’ concern. They were worried about risks of misunderstanding the caller or that the caller would misinterpret given advice. They strived for optimal communication, and to obtain a clear patient picture during calls. For this, RNs asked callers a variety of questions, mainly about symptoms to come further in disease detection.
Many RNs tried to figure out if the caller was known to them and whether the symptom description was adequate. The importance of noticing implicit cues, such as background sounds, e.g. a supporting spouse, was underlined. Some callers were reported to describe their symptoms in detail and perhaps exaggerate, in order to get a GP appointment. Contrary to this, others provided brief information and underestimated serious symptoms:
Some say well, they are not very sick, and some are very sick, though they may not seem very sick, so it is … I think it is basically difficult. Because you can get tricked by those who say, well, it’s not so bad … yes. But they are in fact very sick. (Interview 7)
Due to lack of observable signs, the RNs reported that they must rely on what they heard. For example, apart from caller descriptions of breathing problems, they also listened to callers’ breathing and coughs. When RNs felt uncertain, they asked GPs at the PHCC for advice. In some PHCCs, RNs could offer face-to-face RN consultations, when the patient condition was unclear.
That’s what we do, in dubious cases we can … have the possibility to get them over here in some way and make an assessment … then you are able to see their skin colour and lots of other things. (Interview 4)
Differentiate harmless from severe problems
Another demanding assignment highlighted by the RNs, was to make correct assessments regarding symptom severity and whether the caller should see a physician (urgent or non-urgent) or receive RN self-care advice. The necessity to base assessments on thorough medical histories was emphasized. A need for sensitivity, nursing experience, and medical knowledge was also suggested in order to facilitate interpretation and assessments of the callers’ condition over the telephone. The RNs were well aware of the risk of telephone nursing, regarding making the right decision, e.g. concerning if the person could manage with self-care advice, should get a GP appointment at once or could wait a few days. In this respect, the RNs described as functioning as a gatekeeper:
So my job in the assessment is to distinguish what is like … who comes here and what should be self-care, and of what is coming here, what could be something that is more serious? (Interview 3)
The RNs sometimes made probabilistic assessments for diagnosis or considered other serious differential diagnoses. They feared missing serious diseases. Several described how they thought about possible underlying causes besides an infection when they for example were told about a cough. When self-care advice was given, the caller was prompted to call again if the symptoms did not disappear:
Well, all breathing problems and everything, and you would think … yes, it is pulmonary embolism and … these rapid ones, but it’s a cough, there are usually some breathing problems then … mm. Yes, I am very generous by saying they can get in touch in case of any small worsening. (Interview 6)
Regarding assessments, RNs expressed that telephone encounters with parents concerning sick children was the most difficult task in the telephone nursing work. They often felt uncertain about paediatrics and were therefore afraid of making mistakes. It was difficult to get a clear picture as to the degree of the child's illness, through the interview with the parent. Hence, GP appointments for children were given generously, despite a fully booked schedule. It was also reported to be important to comfort and calm parents:
I think that I am probably a bit uncertain there, when it comes to small children, so I may more often give them an appointment with the physician, as I feel that I cannot sort it out over the phone when it comes to children. (Interview 13)
Most of the RNs stated that they valued their work with self-care advice, since they found many respiratory tract infections to be self-healing and wanted to help callers avoid unnecessary antibiotics. The RNs also mentioned callers who were well aware of not using antibiotics unnecessarily, and who did not ask for medication. According to the interviewed RNs, the number of callers with this attitude had increased.
If you kind of explain what it is … then I think people in general are very good about the fact that you should not take antibiotics unnecessarily, they don’t really nag you. (Interview 3)
Cope with caller expectations
Another challenge according to the RNs, was the circumstance whereby some callers were perceived as impatient and required help and cures at once. Even before calling, they had decided to ask for a laboratory test, a GP appointment or antibiotics. Most of the persons experienced as demanding were reported to be young and employed, or on their way to holiday abroad. These people were not receptive to advice according to the RNs.
I don’t think they are sick enough to be brought in … Yes, I think … if for example it’s someone who does not seem very sick, but…they still want to see a physician, because they want to get well quickly as they will be travelling abroad, etc. And it’s like this … they want penicillin, to get well right away, that’s what they think. (Interview 1)
The RNs tried to handle the caller’s expectations by discussing and explaining the reasons for symptoms and whether a GP appointment would be necessary or not. Simultaneously, the RNs underlined their ambition to satisfy the callers, comfort them and make them feel listened to. When unable to meet caller expectations through discussion, the RNs sometimes felt forced to book a GP appointment, even though this was against the guidelines.
Well, the important thing is to make them feel…listened to and they are pleased and they don’t hang up and are dissatisfied or worried or whatever, but you try to satisfy them, that’s what I feel is important. (Interview 11)
The RNs underlined the importance of understanding and considering cultural aspects. Depending on callers’ cultural backgrounds, some could have other expectations than the ‘normal caller’ regarding healthcare, e.g. other traditions regarding self-care advice or use of antibiotics. In these cases, the RN ambition to give self-care advice was often not well received.
It’s a cultural issue, and therefore it’s difficult to give self-care advice, as they don’t want to understand that, no, and it’s about seeing a physician, it’s something within them. (Interview 5)
Parental wishes for a GP paediatric consultation only rarely included a wish for antibiotics according to the interviewed RNs. In these cases, some stated it was equally important to just comfort parents. These had found that many parents were comforted by receiving an RN appointment when their child was ill.
Yes, at least with parents and their children, I may feel, when they … with the ears then, that they say that you don’t need antibiotics treatment and it’s nice not to have to give their children antibiotics, and the parents think so too, and it’s very trying to do it, and of course you don’t want to give the children medication they don’t need. (Interview 1)
Sometimes you think that … bring the children here, a bit because … to calm the parents down. (Interview 6)
Throughout the category analysis, the theme support also emerged from two categories In data. Use working tools and Use professional collaboration. Here, RNs talked about how to get professional support in their work via tools such as guidelines and the DST, and to collaborate with professional colleagues. However, not all informants reported to use these job supports. The two categories under the theme support will be further described below.
Use working tools
Concerning the RNs’ reported use of work support, their use of and adherence to DST and guidelines seemed to vary. Some used the available DST. Others reported to know about it, but did not use it. Some RNs had not heard of the DST. Regarding guidelines, some read these when needed, while others remembered them by heart:
I have them (the guidelines) memorised, I ask questions and then … if I need to read up on it, I look it up and leaf through it. (Interview 3)
When guidelines were explicit, integrated into PHCCs’ local routines, and thus well-known to all PHCC personnel, RNs reported that using them was easier. This made RNs aware of why and with what objectives a certain measure should be taken. When infectious symptom management routines were missing, some RNs reported that they instead tried to figure out what to do in order to fulfil the wishes of individual GPs.
The RNs’ reported that opportunities for support via competence development in CME regarding infectious diseases varied. Some had participated in occasional educational activities, while others desired to be regularly informed. A common opinion was that GPs were offered more opportunities for CME, than RNs. Some RNs reported choosing not to prioritize education on infectious diseases, but rather participated in education in their field of special expertise and responsibility, such as diabetes or smoking cessation:
I have chosen other fields, yes. I guess it feels like the others have also prioritised other topics. Because it feels more … that [infectious diseases] is more for the physicians … but it’s also very important to us, but … the fact that we have chosen topics [education] that are for us to do, redressing a wound and … yes, diabetes, smoking cessation, things like that … but of course one would like to do that [infectious diseases] as well (Interview 10)
Use team collaboration
Another support in work reported by RNs, was to receive feedback in various ways from other professionals. This was particularly important for dealing with uncertainty regarding an assessment of caller symptoms, after a conversation over the phone and booking a GP consultation. Feedback was considered to be a source for learning for the future. This was managed in several ways by the interviewed RNs. Some read the medical records after GP consultations to find out how the physician had assessed the patient symptoms, as a second opinion to their own judgement. No RN expressed having received feedback from GPs in a systematic way. Instead, this had mostly happened on the RNs’ own initiative, who could ask the GP in question for feedback.
Sometimes you can go back in the records, if you have a moment to spare, and see what the physician wrote in the medical records … and what happened. I don’t need to speak to the physician directly, as I can read it myself. That’s what you can do. So that’s a development. (Interview 5)
We try to tell the physicians that they are welcome to give us feedback about our GP bookings, so we can see if that was right or wrong. (Interview 5)
When the RNs felt uncertain and wanted advice from a GP about individual callers on the phone, or in their own clinic, they reported they had to ‘disturb’ the GPs in their work. Thus, this was a mutual problem for both RNs and GPs. The RNs stated that they had learned which GPs were OK to contact.
No, let’s do it while they [patients] are still here [at the RN clinic] and go see the physician and discuss it, what will we do now, what do you think. Then, we always get a reply. (Interview 7)
Some PHCCs were reported to have regular meetings for RNs, with functioning collegial support, where management of individual caller or patient cases could be discussed. Others lacked support forums for joint discussions with colleagues, concerning assessments and management of diverse infectious disease symptoms.
Sometimes you feel, maybe, that you would need to meet, maybe just the RNs, and have a discussion, so we are bringing the same message over the phone, you know. A bit more than we are doing at the moment. (Interview 2)
RNs reporting this, often felt alone in making assessments over the phone. They wished for additional help from colleagues and increased information sharing and recommendations to be used in their work with callers. Hence, there were few opportunities for discussing issues when uncertain. Consequently, unpaid lunch breaks were sometimes used for collegial support, according to the interviewed RNs:
I guess generally … that we are talking to each other, the RNs. Yes, we do. Yes … [laughing] … during our lunch … Now, I have had this and that… in the assessment, and imagine that … this child had been sick for two days, like, and the mother is coming ... we can bring up different issues, what we will do. Yes, we communicate with each other, what did you do then? (Interview 2)