National Telephone Advice Nursing in Sweden : Patient Safety and Communication

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