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National Telephone Advice Nursing in Sweden: Patient Safety and Communication
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of this thesis was to investigate patient safety and communication within national telephone advice nursing (SHD) in Sweden. Four empirical studies with different perspectives were conducted. The aim of Study I was to describe telenurses’ experiences of working with computerized decision support systems and how such systems could influence their work. The telenurses described a duality of perceptions: the CDSS both supported and inhibited their work. Study II aimed at describing medical errors that had led to an incident report within the context of SHD. Incident reports sent to and from the SHD during 2007 were collected. The results showed that telenurses have limited possibilities to refer callers to the appropriate level of care, and that other healthcare providers reported that telenurses had made an incorrect assessment regarding callers’ need for care. Study III aimed at describing the actual communication between telenurses and callers expecting a higher level of care than recommended by telenurses, and at investigating relationships within the communication between telenurses and callers. The results showed that telenurses were more prone to use closed-ended questions and did not follow up on callers’ understanding of the advice given. There was also a statistically significant positive relationship between callers’ expressions of Concern and telenurses’ expressions of Criticism, and also between utterances of Criticism between the parties. The aim of Study IV was to describe the characteristics of all malpractice claims following telephone calls to SHD, including the identified causes, the healthcare providers’ measures, and the actual communication between the telenurses and callers. The results showed that among the cases, 13 of 33 patients died and 12 were admitted to intensive care. The National Board of Health and Welfare’s (NBHW) investigations most commonly reported communication failure as the cause of the malpractice claims. The measures reported by SHD most commonly involved discussion in work groups and education of staff. Communication analysis showed a positive correlation between the callers’ expressions of Concern and the telenurses’ expressions of Reassurance. The results also showed communication patterns similar to those found in Study III. Hence, telenurses’ communicative strategies are not in line with the “dialogue process” they are educated in and could be regarded as a threat to patient safety.

In conclusion, the importance of high quality communication is undoubted within telephone advice nursing, and specific training and supervision in communication for telenurses might contribute to improving their communicative competence as well as patient safety. Adapting the CDSS into encourage telenurses to explore callers’ reasons for calling and to follow up on understanding might facilitate patient safety. Organizations also need to take a system-wide approach when addressing patient safety issues and ensure that telenurses are given the resources they need to fulfill their work.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 59 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 788
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
URN: urn:nbn:se:uu:diva-175262ISBN: 978-91-554-8404-0 (print)OAI: oai:DiVA.org:uu-175262DiVA: diva2:532709
Public defence
2012-09-20, Sal IX, Universitetshuset, Biskopsgatan 3, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2012-08-29 Created: 2012-06-04 Last updated: 2013-01-22Bibliographically approved
List of papers
1. Telenurses' experiences of working with computerized decision support: supporting, inhibiting and quality improving
Open this publication in new window or tab >>Telenurses' experiences of working with computerized decision support: supporting, inhibiting and quality improving
2009 (English)In: Journal of Advanced Nursing, ISSN 0309-2402, E-ISSN 1365-2648, Vol. 65, no 5, 1074-1083 p.Article in journal (Refereed) Published
Abstract [en]

AIM: This paper is a report of a study conducted to describe telenurses' experiences of working with computerized decision support systems and how such systems could influence their work. BACKGROUND: Telenursing is an expanding service in many Western countries, and in recent years centralization of telenursing services has occurred in Sweden. In connection with this, the use of computerized decision support has increased. METHOD: Eight Registered Nurses from three telephone advice call centres in Sweden who were using computerized decision support took part in semi-structured interviews in 2006. The data were analysed using qualitative content analysis. FINDINGS: The findings are presented as one theme and three categories. Telenurses experienced their work with a decision support system as supporting, inhibiting and quality improving. Based on two of the categories - 'supporting' and 'inhibiting' - a theme was revealed: being strengthened, but simultaneously controlled and inhibited. This theme represents the individual level. The telenurses found that the decision support system simplified their work, complemented their knowledge, gave them security and enhanced their credibility. They also described experiencing the system as incomplete, sometimes in conflict with their own opinions and controlling. The third category referred to the organizational level: the decision support system ensured the quality of telenursing. CONCLUSIONS: Although the telenurses experienced computerized decision support as both supporting and inhibiting, they preferred working with it. They also described how a computerized decision support system cannot replace telenurses' knowledge and competence, and that it should be considered as complementary.

Keyword
communications skills, competence, computerized decision support, experiences, knowledge, qualitative research, telenurses
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-102325 (URN)10.1111/j.1365-2648.2009.04966.x (DOI)000264821000017 ()19399984 (PubMedID)
Available from: 2009-05-06 Created: 2009-05-06 Last updated: 2017-12-13Bibliographically approved
2. Incident reporting within nurse-led national telephone triage in Sweden: reported errors reveal a pattern that needs to be broken
Open this publication in new window or tab >>Incident reporting within nurse-led national telephone triage in Sweden: reported errors reveal a pattern that needs to be broken
2010 (English)In: Journal of Telemedicine and Telecare, ISSN 1357-633X, E-ISSN 1758-1109, Vol. 16, no 5, 243-247 p.Article in journal (Refereed) Published
Abstract [en]

We conducted a retrospective study of incident reports concerning the national, nurse-led telephone triage system in Sweden. The Swedish Health Care Direct organization (SHD) is staffed by registered nurses who act as telenurses and triage the callers' need for care, using a computerized decision support system. Data were collected during 2007 from all county councils that participated in the SHD and were analysed using content analysis. Incident reports were then compared concerning differences in reported categories and who reported the errors. The 426 incident reports included 452 errors. Of the analysed incident reports, 41% concerned accessibility problems, 25% incorrect assessment, 15% routines/guidelines, 13% technical problems and 6% information and communication. The most frequent outgoing incident reports (i.e. sent from SHD to other health-care providers) concerned accessibility problems and the most frequently incoming reports (i.e. sent to SHD from other health-care providers) concerned incorrect assessment. There was a significant difference (P <  0.001) between outgoing and incoming reports regarding the main category. Telenurses have limited possibilities for referring the caller to their primary health-care provider or specialist, which may cause them to over-triage or under-triage the callers' need for care. This over-triage or under-triage may in turn cause other health-care providers to report incorrect assessment to SHD. The implications for practice are that poor accessibility is a matter that should be addressed and that the reasons for incorrect assessment should be explored.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-119773 (URN)10.1258/jtt.2009.090813 (DOI)000280360000004 ()20457800 (PubMedID)
Available from: 2010-03-01 Created: 2010-03-01 Last updated: 2017-12-12
3. Communication challenges in Swedish telephone advice nursing: analysis of actual calls
Open this publication in new window or tab >>Communication challenges in Swedish telephone advice nursing: analysis of actual calls
Show others...
2011 (English)Article in journal (Refereed) Submitted
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-159276 (URN)
Available from: 2011-09-26 Created: 2011-09-26 Last updated: 2013-03-07Bibliographically approved
4. Malpractice claims regarding calls to Swedish telephone advice nursing: what went wrong and why?
Open this publication in new window or tab >>Malpractice claims regarding calls to Swedish telephone advice nursing: what went wrong and why?
2012 (English)In: Journal of Telemedicine and Telecare, ISSN 1357-633X, E-ISSN 1758-1109, Vol. 18, no 7, 379-383 p.Article in journal (Refereed) Published
Abstract [en]

We analysed the characteristics of all malpractice claims arising out of telephone calls to Swedish Healthcare Direct (SHD) during 2003–2010 (n = 33). The National Board of Health and Welfare's (NBHW) investigations describing the causes of the malpractice claims and the healthcare providers' reported measures were analysed using Qualitative Content Analysis. The original telephone calls themselves, which had been recorded, were analysed using the Roter Interaction Analysis System (RIAS). Among the 33 cases, 13 patients died and 12 were admitted to intensive care. Failure to listen to the caller (n = 12) was the most common reason for malpractice claims, and work-group discussion (n = 13) was the most common measure taken to prevent future re-occurrence. Male patients (n = 19) were in the majority, and females (n = 24) were the most common callers. The most common symptoms were abdominal (n = 11) and chest pain (n = 6). Telenurses followed up on caller understanding in six calls, and mainly used closed-ended questions. Despite the severity of these malpractice claims, the measures taken mainly addressed active failure, rather than the latent conditions. Third-party communication should be regarded as a risk. When callers make repeated contacts, telenurses need to re-evaluate their need for care.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-175259 (URN)10.1258/jtt.2012.120416 (DOI)000311522300003 ()
Available from: 2012-06-04 Created: 2012-06-04 Last updated: 2017-12-07

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