Evaluation of telenursing outcomes: satisfaction, self-care practices, and cost savings

Teleoncology: Novel Approaches for Improving Cancer Care in North America

Due to widespread healthcare workforce shortages, many patients living in remote and rural North America currently have reduced access to various medical specialists. These shortages, coupled with the aging North American population, highlight the need to transform contemporary healthcare delivery systems. The exchange of medical information via telecommunication technology, known as telemedicine, offers promising solutions to address the medical needs of an aging population and the increased demand for specialty medical services. This progressive movement has also improved access to quality health care by mitigating the current shortage of trained subspecialists. Minimizing the effects of these shortages is particularly urgent in the care of cancer patients, many of whom require regular follow-up and close monitoring. Cancer patients living in remote areas of North America have reduced access to specialized care and, thus, have unacceptably high mortality and morbidity rates. Teleoncology, or the use of telemedicine to provide oncology services remotely, has the ability to improve access to high-quality care and assist in alleviating the burden of some of the severe adverse events associated with cancer. In this review, the authors describe how recent advances in teleoncology can reduce healthcare disparities and improve future cancer care in North America.

Telenursing: The view of care professionals in selected EU countries. A pilot study

Background

With the growth of digital nursing, several studies have focused on recording patients' views on remote care, or specialised nurse staffing aspects. This is the first international survey on telenursing focused exclusively on clinical nurses that analyses the dimensions of usefulness, acceptability, and appropriateness of telenursing from the staff point of view.

Methods

A previously validated structured questionnaire including demographic variables, 18 responses with a Likert-5 scale, three dichotomous questions, and one overall percentual estimation of holistic nursing care susceptible to being undertaken by telenursing, was administered (from 1 September to 30 November 2022) to 225 clinical and community nurses from three selected EU countries. Data analysis: descriptive data, classical and Rasch testing.

Results

The results show adequacy of the model for measurement of the domains of usefulness, acceptability, and appropriateness of telenursing (overall Cronbach's alpha 0.945, Kaiser-Meyer-Olkin 0.952 and Bartlett's p < 0.001). Answers in favour of telenursing ranked 4 out of 5 in Likert scale, both globally and by the three domains. Rasch: reliability coefficient 0.94, Warm's main weighted likelihood estimate reliability 0.95. In the ANOVA analysis, the results for Portugal were significantly higher than those for Spain and Poland, both overall and for each of the dimensions. Respondents with bachelor's, master's and doctoral degrees score significantly higher than those with certificates or diplomas. Multiple regression did not yield additional data of interest.

Conclusions

The tested model proved to be valid, but although the majority of nurses are in favour of telenursing, given the nature of the care, which is mainly face-to-face, according to the respondents, the chances of carrying out their activities by telenursing is only 35.3%. The survey provides useful information on what can be expected from the implementation of telenursing and the questionnaire proves to be a useful tool to be applied in other countries.

Intuitive, Efficient and Ergonomic Tele-Nursing Robot Interfaces: Design Evaluation and Evolution

Tele-nursing robots provide a safe approach for patient-caring in quarantine areas. For effective nurse-robot collaboration, ergonomic teleoperation and intuitive interfaces with low physical and cognitive workload must be developed. We propose a framework to evaluate the control interfaces to iteratively develop an intuitive, efficient, and ergonomic teleoperation interface. The framework is a hierarchical procedure that incorporates general to specific assessment and its role in design evolution. We first present pre-defined objective and subjective metrics used to evaluate three representative contemporary teleoperation interfaces. The results indicate that teleoperation via human motion mapping outperforms the gamepad and stylus interfaces. The trade-off with using motion mapping as a teleoperation interface is the non-trivial physical fatigue. To understand the impact of heavy physical demand during motion mapping teleoperation, we propose an objective assessment of physical workload in teleoperation using electromyography (EMG). We find that physical fatigue happens in the actions that involve precise manipulation and steady posture maintenance. We further implemented teleoperation assistance in the form of shared autonomy to eliminate the fatigue-causing component in robot teleoperation via motion mapping. The experimental results show that the autonomous feature effectively reduces the physical effort while improving the efficiency and accuracy of the teleoperation interface.

Calling an Oncological Emergency Telephone to Seek Advice: An Interview Study

BACKGROUND

Cancer treatment is increasingly provided on an outpatient basis, which may challenge patients and caregivers coping with illness and adverse effects at home. A telephone consultation is an accepted type of healthcare provision to support patients and prevent adverse outcomes when their capacity to self-manage is inadequate. Whether this option for help sufficiently supports patients needs further investigation.

OBJECTIVES

The aim of this study was to explore patients' and caregivers' experience of calling an oncological emergency telephone.

METHODS

The study applies a phenomenological hermeneutic approach with 12 semistructured interviews. Patients and caregivers who had called the oncological emergency telephone within the last 2 months were included. The interview texts were analyzed by content analysis.

RESULTS

Patients and caregivers perceive the emergency telephone as a lifeline that they consider calling when the patient's condition changes from what they understand as normal to what they perceive as abnormal. They would rather call "one time too many than one time too few" if their resources are inadequate to ensure their safety. The tone, attitude, and professional competency of healthcare providers affect patients' experience of the call.

CONCLUSIONS

The value of calling the oncological emergency telephone depends on the healthcare providers' professional competences and skills to establish a relationship that makes patients feeling accommodated and taken care of.

IMPLICATIONS FOR PRACTICE

Patients' and caregivers' perceptions of what constitutes a good telephone consultation represent significant knowledge that contributes to a more comprehensive and practice-based understanding of what is required to advise patients and caregivers in an oncological emergency telephone.

Users' acceptability of a mobile application for persons with type 2 diabetes: a qualitative study

Background

The use of mobile health apps is now common in diabetes self-management and acceptability of such tools could help predict further use. There is limited research on the acceptability of such apps: use over time, the factors and features that influence self-management, how to overcome barriers, and how to use an app in relation to health-care personnel.

In this study, we aimed to obtain an in-depth understanding of users’ acceptability of a mobile app for diabetes self-management, and to explore their communication with health-care personnel concerning the app.

Methods

The study had a qualitative descriptive design. Two researchers conducted 24 semi-structured in-depth interviews with adults with type 2 diabetes who had used a digital diabetes diary app for 1 year, during participation in the Norwegian Study in the EU project RENEWING HeALTH. We recruited the participants in a primary health-care setting. The transcripts of the interviews were analyzed using qualitative content analysis on developing themes, which we interpreted according to a theory of acceptability. We used NVivo 11 Pro during the process.

Results

The users’ acceptability of the app diverged. Overall, the responses indicated that the use of a digital diabetes diary requires hard work, but could also ease the effort involved in following a healthy lifestyle and better-controlled levels of blood glucose. Crucial to the acceptability was that a routine use could give an overview of diabetes registration and give new insights into self-management. In addition, support from health-care personnel with diabetes knowledge was described as necessary, either to confirm the decisions made based on use of the app, or to get additional self-management support. There were gradual transitions between practical and social acceptability, where utility of the app seems to be necessary for both practical and social acceptability. Lack of acceptability could cause both digital and clinical distress.

Conclusions

Both practical and social acceptability were important at different levels. If the users found the utility of the app to be acceptable, they could tolerate some lack of usability. We need to be aware of both digital and clinical distress when diabetes apps form a part of relevant health-care.

Trial registrations

Self-management in Type 2 Diabetes Patients Using the Few Touch Application, NCT01315756, https://clinicaltrials.gov/show/NCT01315756 March 15, 2011.

Cost analysis of an integrated aged care program for residential aged care facilities

Objective To compare annual costs of an intervention for acutely unwell older residents in residential age care facilities (RACFs) with usual care. The intervention, the Aged Care Emergency (ACE) program, includes telephone clinical support aimed to reduce avoidable emergency department (ED) presentations by RACF residents. Methods This costing of the ACE intervention examines the perspective of service providers: RACFs, Hunter Medicare Local, the Ambulance Service of New South Wales, and EDs in the Hunter New England Local Health District. ACE was implemented in 69 RACFs in the Hunter region of NSW, Australia. Analysis used 14 weeks of ACE and ED service data (June–September 2014). The main outcome measure was the net cost and saving from ACE compared with usual care. It is based on the opportunity cost of implementing ACE and the opportunity savings of ED presentations avoided. Results Our analysis estimated that 981 avoided ED presentations could be attributed to ACE annually. Compared with usual care, ACE saved an estimated A$921214. Conclusions The ACE service supported a reduction in avoidable ED presentations and ambulance transfers among RACF residents. It generated a cost saving to health service providers, allowing reallocation of healthcare resources. What is known about the topic? Residents from RACFs are at risk of further deterioration when admitted to hospital, with high rates of delirium, falls, and medication errors. For this cohort, some conditions can be managed in the RACF without hospital transfer. By addressing avoidable presentations to EDs there is an opportunity to improve ED efficiency as well as providing care that is consistent with the resident’s goals of care. RACFs generate some avoidable ED presentations for residents who may be more appropriately treated in situ. What does this paper add? Telephone triaging with nursing support and training is a means by which ED presentations from RACFs can be reduced. One of the consequences of this intervention is ‘cost avoided’, largely through savings on ambulance costs. What are the implications for practitioners? Unnecessary transfer from RACFs to ED can be avoided through a multicomponent program that includes telephone support with cost-saving implications for EDs and ambulance services.

Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing

Childhood obesity is a serious health issue, associated with medical comorbidity and psychosocial impairment that can persist into adulthood. In the United States, youth with intellectual and developmental disabilities are more likely to be obese than youth without disabilities. A large body of evidence supports the efficacy of family-based treatment of childhood obesity, including diet, physical activity, and behavior modification, but few interventions have been developed and evaluated specifically for this population. We highlight studies on treatment of obesity among youth with intellectual and developmental disabilities, including both residential/educational settings as well as outpatient/hospital settings. All interventions were delivered in-person, and further development of promising approaches and delivery via telenursing may increase access by youth and families. Nursing scientists can assume an important role in overcoming barriers to care for this vulnerable and underserved population.

Impact of a telenursing service on satisfaction and health outcomes of children with inflammatory rheumatic diseases and their families: a crossover randomized trial study protocol

BACKGROUND

Pediatric rheumatic diseases have a significant impact on children's quality of life and family functioning. Disease control and management of the symptoms are important to minimize disability and pain. Specialist clinical nurses play a key role in supporting medical teams, recognizing poor disease control and the need for treatment changes, providing a resource to patients on treatment options and access to additional support and advice, and identifying best practices to achieve optimal outcomes for patients and their families. This highlights the importance of investigating follow-up telenursing (TN) consultations with experienced, specialist clinical nurses in rheumatology to provide this support to children and their families.

METHODS/DESIGN

This randomized crossover, experimental longitudinal study will compare the effects of standard care against a novel telenursing consultation on children's and family outcomes. It will examine children below 16 years old, recently diagnosed with inflammatory rheumatic diseases, who attend the pediatric rheumatology outpatient clinic of a tertiary referral hospital in western Switzerland, and one of their parents. The telenursing consultation, at least once a month, by a qualified, experienced, specialist nurse in pediatric rheumatology will consist of providing affective support, health information, and aid to decision-making. Cox's Interaction Model of Client Health Behavior serves as the theoretical framework for this study. The primary outcome measure is satisfaction and this will be assessed using mixed methods (quantitative and qualitative data). Secondary outcome measures include disease activity, quality of life, adherence to treatment, use of the telenursing service, and cost. We plan to enroll 56 children.

DISCUSSION

The telenursing consultation is designed to support parents and children/adolescents during the course of the disease with regular follow-up. This project is novel because it is based on a theoretical standardized intervention, yet it allows for individualized care. We expect this trial to confirm the importance of support by a clinical specialist nurse in improving outcomes for children and adolescents with inflammatory rheumatisms.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT01511341 (December 1st, 2012).

[Evaluation of a new telephone counseling protocol used by the admission nurse of a pediatric emergency department]

INTRODUCTION

Telephone counseling is a daily occurrence in the pediatric emergency department (ED). It is difficult and has no legal framework. In 2010, we created a new protocol aimed at improving the telephone counseling given by the admission nurse at our pediatric emergency department: an index card is created for every call, color-coded according to severity with a list of clinical items, allowing for simple and reproducible advice.

MATERIALS AND METHODS

The aim of this study was to evaluate the reliability of the cards. We conducted a prospective analysis, from June 2011 to January 2012, to analyze every card generated for seven major reasons for calling. The study was designed to: (a) measure the level of accurate completion of the cards by the admission nurse; (b) evaluate the quality of the advice given, as defined by the color coding.

RESULTS

Of 3297 calls received, 1033 cards were included in the analysis: 504 (49%) of these cards were correctly completed for optimal traceability (complete administrative and clinical data, correct color coding). The level of completion significantly increased for admission nurses who had filled in more than ten cards. Among these 504 calls, 386 cards (77%) delivered appropriate advice and 87 (17%) inappropriate advice. Thirty-one cards (6%) could not be evaluated for the quality of the advice given. There was no significant difference between the different causes for calling. Overall, only ten calls (less than 2%) resulted in underestimation of the severity of the child's condition, and 9% in overestimation (leading to an unnecessary consultation in the ED).

DISCUSSION

The quality of card completion needs to improve, especially since this study demonstrates how easy it is to use these cards. They ensure exhaustive questioning; guide the admission nurse toward safer advice, with appropriate advice given in 77% of cases. The rate of underestimated severity is low, and the initial severity of these cases is debatable because half of these cases consulted at the ED 12-24h after the initial call.

CONCLUSION

These innovative color-coded cards make it possible to dispense reliable and harmonized advice. They ease the process of an otherwise difficult exercise.

Telehealth nurse practitioner student clinical experiences: an essential educational component for today's health care setting

In order to meet the continuous changes and innovations within the health care system, nurse practitioner faculty must look to the future and prepare nurse practitioner graduates who deliver safe, quality patient care addressing the realities of a global society with a fast-paced expansion of technologies. Preparing nurse practitioner students for practice must include more than information technology knowledge in graduate nursing programs. Formal clinical experiences using various telehealth applications must be integrated into nurse practitioner training. Innovative strategies must be explored by nurse practitioner faculty to assure that graduates can meet the demanding technological demands of our current health care society.

Patient compliance with telephone triage recommendations: a meta-analytic review

OBJECTIVE

To systematically investigate the extent to which patients comply with triage advice from telenurses and to identify factors that potentially influence compliance.

METHODS

Findings from 13 studies identified through interdisciplinary research databases (1990-2010) were meta-analyzed. Separate pooled analyses compared patients' compliance rates for emergency services and office care (13 outcomes), emergency services and self care (13 outcomes), and self care and office care (12 outcomes).

RESULTS

Overall patient compliance was 62%, but varied by intensity of care recommended with low compliance rates for advice to see a general practitioner. Reasons for noncompliance include patients reporting to have heard a different disposition, patients' intentions and health beliefs.

CONCLUSION

Patient compliance to triage recommendations was influenced by the interactive role of patient perceptions and the quality of provider communication, both of which were mediated by access to health services. Further research is needed to clarify whether noncompliance is attributable to poor communication by the nurse or patient misinterpretation.

PRACTICE IMPLICATIONS

We highlight the need for communication-skills training in a telephone-consultation context that is patient centered, and specifically addresses building active listening and active advising skills and advantages to structuring the call.

Smarter elder care? A cost-effectiveness analysis of implementing technology in elder care

Whereas in most sectors, technology has taken over trivial and labour consuming tasks, this transformation has been delayed in the healthcare sector. Although appropriate technology is available, there is general resistance to substituting 'warm' hands with 'cold' technology. In the future, this may change as the number of elderly people increases relative to the people in the work force. In combination with an increasing demand for healthcare services, there are calls for efforts to increase productivity in the sector. Based on experience data from previous studies on information and communication technology efforts in the healthcare sector, we quantitatively assess the use of smart house technology and video visits in home care. Having identified healthcare providers, hospitals and relatives as the main affected groups, we show that smart house technology is cost-effective, even if only relatives gain from it. Video visits, which have higher implementation costs, demand effects on both relatives and health care providers in order to be a cost-effective tool in home care. As the analysis is purely quantitative, these results need to be complemented with qualitative effects and with more thorough discussions of the ethical, medical and legal aspects of the use of technology in home care.

Caller self-care decisions following teletriage advice

AIM

To examine caller self-care decisions following teletriage advice provided by nurses.

BACKGROUND

The use of teletriage is gaining popularity as one way of enhancing capacity for self-care. Research from several countries suggests that teletriage reduces the use of other healthcare services without compromising safety. However, there is little or no research related to how often self-care advice is provided and whether or not callers follow the advice.

DESIGN

A descriptive survey design was used with a random sample of 312 callers who were advised by a teletriage nurse to engage in self-care.

METHOD

Callers were randomly selected from all calls to a teletriage service each day of the month for nine months. Data were collected using a researcher-developed interview guide and analysed using a variety of inferential statistics for forced choice questions and content analysis for open-ended questions.

RESULTS

The majority of callers who were advised to engage in self-care reported doing so. Callers with greater self-efficacy and satisfaction with the nurse interaction were more likely to follow advice to self-care. All callers would call the teletriage service again for the same or a different issue.

CONCLUSION

Teletriage callers were confident in the advice provided and were willing to continue to use the service.

RELEVANCE TO CLINICAL PRACTICE

This study indicates that teletriage programmes are a cost-effective way of addressing self-care needs of individuals who might otherwise visit an emergency department.

e-Health Technologies in Home Care Nursing

The innovative impact of advancing e-Health technologies is more frequently being discussed in nursing science. Nurses play an important role in collecting data and giving support to other users, especially in home care. Since issues of acceptance play a major role, the following article, which presents findings based on a focus group consisting of the elderly, caretaking relatives and professional nurses, is discussed from an ethical point of view in the context of international debate. It is interesting to note, that to some extent there is substantial ambivalence in the willingness to integrate such technologies into daily care. A need for technical assistance is clearly recognizable, however, limits as well. The authors’ findings indicate that a fundamental discussion on the relevance of e-Health methods in professional nursing needs to be held. It should address the ethical questions of often conflicting interests and rights (protection of identity, privacy and safety) in situations of high vulnerability.

The Impact of Work Environment on Telephone Advice Nursing

Telephone advice nursing (TAN) is part of a current effort to improve patient access while reducing cost and encouraging self-care. However, the environment in which TAN occurs can significantly affect both nurse and patient outcomes. This research builds on findings from a large health maintenance organization study by Valanis et al. in which questionnaires and call descriptions were used to correlate TAN nurse and caller/patient perceptions of calls at three regional sites. The survey tools were used to identify nurse perceptions of their work environments (WEs) as well as caller perceptions of using the advice service. The sample included 88 nurse questionnaires and 865 caller questionnaires. Multivariate analysis of covariance revealed significant site perception differences in the WE of stress, communication, and autonomy, whereas no significant differences were noted in collegial relationships and organizational support. Each site was also determined to be a unique predictor of patient perceptions of satisfaction with the advice. Findings indicate nursing professionals act as a filter to mask stressful WE effects experienced by nurses and ensure patient outcomes thereby supporting patient satisfaction with the service.

Alternative delivery methods for pharmacy services

In many developed countries, the provision of pharmacy services is no longer restricted to the traditional “walk-in” or face-to-face approach. This paper examines whether alternative delivery methods provide patients with pharmacy services that meet their medication and related information needs, and discusses professional issues and the implications for practice. Although not appropriate for everyone, studies show that many patients do accept the alternative means of service delivery examined here. For some patients, such as those with mobility problems or who live in remote areas, technology-driven alternatives may be preferred. Health care professionals must take steps to address legitimate concerns about the protection of patient safety and confidentiality. To increase patient choice, the pharmacy profession needs to look closely at the positive aspects of these alternatives, as they can be incorporated in “traditional” pharmacy practice.

Déploiement de nouveaux rôles infirmiers au Québec et pouvoir médical

Université de Montréal.Le contexte actuel des systèmes de santé occidentaux réclame que des transformations soient opérées dans les modes d’organisation et de dispensation des soins de santé. Pour faire face à ces nouveaux défis, de nombreux établissements ont introduit de nouveaux rôles infirmiers ayant le potentiel de transformer l’offre de services. Cet article a comme but de mieux comprendre le déploiement de ces nouveaux rôles infirmiers en contexte québécois et d’identifier les facteurs qui favorisent ou entravent leur mise en oeuvre, en portant un intérêt particulier à la dimension du pouvoir médical. Notre analyse montre que l’introduction de nouveaux rôles nécessite que soient redéfinis les espaces d’autorité exercés par la profession médicale sur la prestation de l’ensemble des services de santé, incluant les services infirmiers. La question du pouvoir médical, aussi délicate soit-elle, est d’autant plus importante que la négociation des frontières entre la profession infirmière et la profession médicale se présente comme un incontournable pour maximiser le plein potentiel de ces rôles et atteindre les objectifs poursuivis en termes d’accessibilité, de globalité et de qualité des services.

The appropriateness of referrals to a pediatric emergency department via a telephone health line

OBJECTIVE

We compared the appropriateness of visits to a pediatric emergency department (ED) by provincial telephone health line-referral, by self- or parent-referral, and by physician-referral.

METHODS

A cohort of patients younger than 18 years of age who presented to a pediatric ED during any of four 1-week study periods were prospectively enrolled. The cohort consisted of all patients who were referred to the ED by a provincial telephone health line or by a physician. For each patient referred by the health line, the next patient who was self- or parent-referred was also enrolled. The primary outcome was visit appropriateness, which was determined using previously published explicit criteria. Secondary outcomes included the treating physician's view of appropriateness, disposition (hospital admission or discharge), treatment, investigations and the length of stay in the ED.

RESULTS

Of the 578 patients who were enrolled, 129 were referred from the health line, 102 were either self- or parent-referred, and 347 were physician-referred. Groups were similar at baseline for sex, but health line-referred patients were significantly younger. Using explicitly set criteria, there was no significant difference in visit appropriateness among the health line-referrals (66%), the self- or parent-referrals (77%) and the physician-referrals (73%) (p = 0.11). However, when the examining physician determined visit appropriateness, physician-referred patients (80%) were deemed appropriate significantly more often than those referred by the health line (56%, p < 0.001) or by self- or parent-referral (63%, p = 0.002). There was no significant difference between these latter 2 referral routes (p = 0.50). In keeping with their greater acuity, physician-referred patients were significantly more likely to have investigations, receive some treatment, be admitted to hospital and have longer lengths of stay. Patients who were self- or parent-referred, and those who were health line-referred were similar to each other in these outcomes.

CONCLUSION

There was no significant difference in visit appropriateness based on the route of referral when we used set criteria; however, there was when we used treating physician opinion, triage category and resource use.

The effect of perceived health status on patient satisfaction

OBJECTIVE

To examine the effect of perceived health status on three components of patient satisfaction.

METHODS

The Household Component of the 1999 Medical Expenditure Panel Survey for people 35-64 years of age was used to examine the effect of perceived health status on patient satisfaction measured in terms of access to care, provider quality and quality of care. Descriptive statistics and multivariate regression were used to describe the subjects and to examine the relationship between patient satisfaction and perceived health status controlling for patient demographic factors, health factors and provider characteristics. All analyses used STATA 8.0 which is designed to analyze weighted data.

RESULTS

A total of 4,417 patients (71% women) met the inclusion criteria for the study. Patients who rated their health excellent or good scored higher on the three dimensions of patient satisfaction. Higher scores on one or more components of patient satisfaction were associated with being older, married, better educated and having higher income, health insurance and good mental health. Seeing the health-care provider for an old problem resulted in lower levels of patient satisfaction. Provider characteristics significantly related to patient satisfaction were listening to the patient, being a specialist, seeing patients in an office setting and being located in the South.

CONCLUSIONS

This study has shown that patient satisfaction is influenced by a person's self-perceived health status and other personal characteristics that are external to the delivery of health care. These findings suggest that patient satisfaction data should be used judiciously because a significant portion of the variation may be attributed to factors endogenous to the patient and therefore are not amenable to provider intervention.

Solution-focused conversations: a new therapeutic strategy in well child health nursing telephone consultations

AIM

This paper is a report of a study to explore well child nurses' perceptions of outcomes resulting from the use of solution-focused conversations in their telephone consultations with clients.

BACKGROUND

Well child nurses (health visitors) in some services provide a separate telephone consultation service for parents who need immediate advice or are unable to visit the clinic. As well as purely physical issues suggesting infant pathology, these consultations address a range of other concerns relating to parenting and child behaviour. The standard problem-solving approach used to address physical issues is less effective for various non-physical concerns, where different communication strategies may be helpful.

METHOD

In this qualitative, action-oriented study, a small group of well child telenurses in New Zealand was introduced to a specific communication strategy, called 'solution-focused conversations', during 2005. They applied this approach in their practice and then reflected together on their experiences in focus groups.

FINDINGS

The nurses considered that the solution-focused conversations enabled clients to: recognize the nature of the parenting issue of concern that had motivated their call; identify more effective parenting practices to address specific issues with their child; increase their confidence in their own parenting capabilities.

CONCLUSION

This study suggested the value of learning a specific communication strategy for the practice of a group of well child telenurses. Solution-focused conversation is a suitable approach for the single, relatively short, interactions involved in telephone nursing. Other communication strategies could be appropriate for nurses in different clinical situations.

Decision aid software programs in telenursing: not used as intended? Experiences of Swedish telenurses

Telenurses at call centers use decision aid software programs to offer triage recommendations and self-care advice to the general public. Decision aid programs are intended to support medical safety but were suggested by telenurses to be a hindrance to the dialogue. The aim of this study was to explore the use of decision aid software programs for telenursing, from the perspective of the users. A qualitative, descriptive approach was used. Twelve telenurses in Sweden were interviewed twice. The interviews were transcribed and analyzed thematically. Four themes were found: support for assessment but not for the decision; inconsistency between actual practice and the decision aid software; limited support for learning and information; and communication challenges and software programs. The software programs were a support for assessment, rather than decision-making, assuring the nurses that the relevant questions were asked. They were not fully adapted to current clinical practice, focusing mainly on acute conditions. Nurses worked to a large extent with self-care advice, often over-riding the recommendations made.

Computer-supported telephone nurse triage: an evaluation of medical quality and costs

AIM

To evaluate a telephone nurse triage model in terms of appropriateness of referrals to the appropriate level of care, patient's compliance with given advice and costs.

BACKGROUND

A key concern in each telephonic consultation is to evaluate if appropriate.

METHOD

An evaluative design in primary health care with consecutive patients (N = 362) calling telephone nurse triage between November 2002 and February 2003.

RESULTS

The advice was considered adequate in 325 (97.6%) cases. The patients' compliance with self-care was 81.3%, to primary health care 91.1% and to Accident and Emergency department 100%. The nurses referred self-care cases (64.7%) and Accident and Emergency cases (29.6%) from a less adequate to an appropriate level of care. The cost saving per call leading to a recommendation of self-care was euro 70.3, to primary health care euro 24.3 and to Accident and Emergency department euro 22.2.

CONCLUSIONS

The telephone nurse triage model showed adequate guidance for the patients concerning level of care and released resources for the benefit of both patients and the health care system.

Nurses' perceptions of providing advice via a telephone care line

The provision of advice over the telephone in the health service has become more common in the Western world and in Sweden this task is allocated to nurses. There are several million calls a year to the medical care telephone helpline. Nurses answer the calls, provide advice and direct the flow of patients to the most appropriate treatment level. The aim of this study was to describe how nurses perceive their job of providing telephone advice to patients. Interviews with 12 nurses were analyzed using a phenomenographic approach. The nurses perceived their work as stimulating, autonomous and challenging. They also felt exposed because extensive knowledge is required and there is a risk of being criticized, as they are in a front-line position. Nurses who are responsive, determined and not anxious about their prestige can carry out the work well, provided they have a good level of self-awareness. Personal qualities and the confidence of superiors make even an exposed position with considerable requirements manageable.

Perceptions of Effectiveness of Nurse-Managed Clinics: A Cross-Cultural Study

OBJECTIVE

To study perceptions of the effectiveness of two nurse-managed clinics (NMCs), one in the United States and the other in New Zealand.

DESIGN

Cross-cultural evaluation study utilizing qualitative methodology; two rounds of in-depth interviews were tape recorded, transcribed verbatim, and analyzed for themes.

SAMPLE

Data were initially collected from 21 participants. Sixteen of the original participants participated in a second interview.

INTERVENTION

The first round of interviews and provisional data analysis were conducted in the respective NMCs; joint data analysis to identify themes and develop a preliminary joint report of findings followed. Sixteen participants responded to the provisional report; additional data analysis resulted in the final report of findings.

RESULTS

Analysis of the data yielded three categories: the NMC milieu affects perceived effectiveness; perceptions are shaped by contrasting with past experiences; and the level of care affects personal health care decisions.

CONCLUSIONS

The milieu created in the NMC enhances perceptions of effectiveness and responsibility for personal health care. Further research related to effectiveness of NMC models of care and client outcomes is needed. Qualitative methodology is recommended for cross-cultural research.

Health care access after injury by insurance type in a pediatric population

OBJECTIVES

Previous studies demonstrate discrepancies in health care access by insurance status for routine, discretionary care. It is unknown whether these discrepancies in health care utilization by insurance status persist in urgent/emergent circumstances. We used injury as a sentinel event to represent urgent/emergent medical conditions to examine the relationship with insurance type.

METHODS

Using the 2000, 2001, and 2002 National Health Interview Survey, we examined medical care sought after 1847 injuries among children younger than 18 years. We performed univariate analyses to explore the relationship of insurance type and demographic variables with medical care sought. We then conducted multivariate logistical regression analysis to assess the association of insurance type with only making a telephone call and with being hospitalized while controlling for confounding variables. There was no direct measure in injury severity in these data.

RESULTS

Although uninsured children had the lowest percentage of head injuries, there was no significant difference in body part injured by insurance type. While controlling for potentially confounding variables, there were no significant differences for making only a telephone call after an injury by insurance type [OR (95% CI): 1.29 (0.45-3.72) for private insurance; 1.13 (0.28-4.62) for other insurance types; 0.69 (0.08-6.33) for uninsured; Medicaid as the reference]. However, uninsured children had a significantly increased likelihood of being hospitalized after an injury [OR (95% CI): 4.07 (1.13-14.66) compared with 2.21 (0.73-6.63) for privately insured; 1.61 (0.47-5.55) for other insurance types; Medicaid as the reference].

CONCLUSIONS

While controlling for potentially confounding variables, there was no relationship between type of insurance and only making a telephone call after an injury. However, uninsured children were significantly more likely to be hospitalized after an injury than insured children. This latter relationship differs from overall patterns of health care utilization by insurance type.

The development of a helpline for chronic obstructive pulmonary disease (COPD)

BACKGROUND

The goal of the helpline is to assist individuals with chronic obstructive pulmonary disease (COPD) better manage their disease through improved understanding of COPD, its symptoms and treatment.

OBJECTIVES

The purpose of this project was to develop and validate a protocol for a COPD helpline.

METHODS

Ten key informants with expertise in helpline development or COPD were interviewed. Fifty individuals with COPD participated in content validation of the protocol.

RESULTS

An initial protocol for the helpline aimed to provide: (1) information and education regarding COPD and its management via the telephone and with written materials; (2) guidance regarding course of management; (3) resource links to other support services and programs locally, provincially, and/or nationally; and (4) caring support and reassurance to those with COPD and their families. The majority of the calls from individuals with COPD sought medical information (74%) and required 36.6 +/- 14.5 min (range: 15-85) to complete. Many different topics were discussed, with medication and exercise being the most common. The availability of the call center was identified as one means of replacing information sought from other health care providers, mainly physicians and pulmonary rehabilitation staff.

CONCLUSION

A protocol of a helpline for COPD has been developed based on the literature, theoretical knowledge, and input from key informants and individuals with COPD.

Nurse-managed clinics: issues in evaluation

BACKGROUND

Nurse-managed clinics (NMCs) have been in existence for over 30 years. Evaluation of such clinics has been sparse and most have used entirely quantitative techniques. This article explores the importance of evaluation of NMCs using the Mana Health Clinic in Auckland, New Zealand as an example.

DISCUSSION

Fourth generation evaluation is offered as an appropriate methodology for undertaking evaluation of NMCs. Fourth generation evaluation actively seeks involvement of clients in the process and outcome of the evaluation, resulting in participation and empowerment of stakeholders in the service - a precept often forgotten in traditional evaluation strategies and of vital importance in understanding why people use NMCs. The method proposed here also incorporates the need for quantitative data.

CONCLUSION

The main argument proposed here is that a combination of qualitative and quantitative data sources is likely to give the greatest understanding of NMCs utilization. Evaluation of NMCs is vital to the continuation of this type of health service. However, evaluation must be appropriate to the service being studied. Fourth generation evaluation used to elicit client's perceptions of the clinic along with quantitative data is offered as an appropriate means of achieving this.

Use of a telephone nursing line in a pediatric neurology clinic: one approach to the shortage of subspecialists

OBJECTIVE

There are not enough pediatric neurologists to meet the many needs of pediatric neurology patients. The Hospital for Sick Children has responded by expanding the nursing role in the pediatric neurology outpatient clinic. The objective of this study was to examine the use of a telephone nursing line in this hospital-based pediatric neurology clinic.

METHODS

A cross-sectional study was performed on all telephone call records collected during a 2-week study period. Each initial incoming call concerning a patient was counted as an index call. Associations between clinic type or diagnosis and length of telephone calls were assessed using the chi(2) test.

RESULTS

A total of 208 index calls were received, generating a total of 597 incoming and outgoing calls. The most common clinic types were Epilepsy clinic (35.6%) and General Neurology clinic (32.7%), and the most common patient diagnoses were epilepsy (63.5%) and developmental delay (45.2%). Most patients were between the ages of 1 and <7 years (33.9%) and 12 and <18 years (32.8%) and male (55.2%). Most calls were made by mothers (57.2%) to ask about medical administrative issues (28.4%) and/or symptoms (27.9%). Physicians were notified for 47.1% of calls; nurses were twice as likely to notify physicians for calls concerning new symptoms (relative risk: 2.1; 95% confidence interval: 1.6-2.7). Most calls required between 1 and 5 minutes (49.0%). Long telephone calls (>10 minutes) were strongly associated with a diagnosis of epilepsy.

CONCLUSIONS

There is a high demand for the neurology nursing line in our clinic. Most telephone calls and most long telephone calls concerned patients with epilepsy. Nurses managed more than half of all telephone calls without physician assistance. Use of a nursing line can aid in the provision of care to complicated subspecialty patients. Additional strategies are needed to optimize delivery of care to high-need medical populations.

Patient compliance with medical advice given by telephone

Data on compliance with medical advice given by telephone consultation services are currently lacking. The aim of this study was to assess patient compliance with medical advice given by a call center. A cross-sectional telephone survey was carried out on a random sample of 463 callers 72 hours after contacting the Grenoble Dial 15 center in France. Four hundred nine subjects (88.3%) participated in the study. Of these, 286 callers (69.9%) complied with the medical advice given. Compliance was 61.4% among patients who were advised to treat themselves, 83.9% among patients who were advised to consult a general practitioner during business hours, and 64.0% among patients who were advised to go to an accident and ED (P <.01). The survey pointed out adverse events resulting from the service. Assessing patient compliance can be an important source of information for improving aspects of patient management provided by telephone consultation services.

Advice nursing practice: on the quality of the evidence

OBJECTIVE

The primary objective was to review the research regarding advice nursing practice to determine the content areas investigated and the quality of the evidence.

METHODS

A systematic review of advice nursing research was done in electronic databases, reference lists, and the literature identified by experts (N = 527). After deletion of duplicates and clinical and theoretical articles, full text reviews were done on 62 studies.

RESULTS

Eight thematic content areas were identified: delivery and continuity of care to populations, appropriateness of advice given, patient/provider satisfaction, disposition/utilization after calls, reason for calling, cost analysis, process of decision-making, and documentation. The most frequently investigated subject was delivery/continuity of care (n = 16).

IMPLICATIONS

For certain chronic disease populations, interventions using telephone advice for social support, education, and symptom management improve clinical outcomes. Availability and use of protocols and guidelines do not guarantee standardized care or ensure that appropriate advice will be given. Consumer satisfaction with advice nursing is high, and appears to be related to the intervention component of the nursing process. The priority for future research should be given to those studies that describe the character and suitable dose of the nursing intervention that is advice nursing.

Callers' ability to understand advice received from a telephone health-line service: comparison of self-reported and registered data

OBJECTIVE

To validate users' perception of nurses' recommendations to look for another health resource among clients seeking teleadvice. To analyze the effects of different users' and call characteristics on the incorrectness of the self-report.

DATA SOURCES/STUDY SETTING

This study is a secondary analysis of data obtained from 4,696 randomly selected participants in a survey conducted in 1997 among users of Info-Santé CLSC, a no-charge telenursing health-line service (THLS) available all over the province of Québec.

STUDY DESIGN/DATA COLLECTION

Self-reported advice from follow-up survey phone interviews, conducted within 48 to 120 hours after the participant's call were compared to the data consigned by the nurse in the computerized call record. Covariables concerned characteristics of callers, context of the calls, and satisfaction about the nurses' intervention. Association between these variables and inaccurate reports was identified using multinomial logistic regression analyses.

PRINCIPAL FINDINGS

Advice to consult were recorded by the nurse in 42 percent of cases, whereas 39 percent of callers stated they had received one. Overall disagreement between the two sources is 27 percent (12 percent by false positive and 15 percent by false negative) and kappa is 0.45. Characteristics such as living alone (adjusted OR = 2.5), calls relating to psychological problems (OR = 2.8), perceived seriousness (OR = approximately 2.6), as well as others, were associated with inaccurate reports.

CONCLUSIONS

Telephone health-line providers should be aware that many callers appear to interpret advice to seek additional health care differently than intended. Our findings suggest the need for continuing quality control interventions to reduce miscommunication, insure better understanding of advice by callers, and contribute to more effective service.

Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature

The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.