The impact of using computer decision-support software in primary care nurse-led telephone triage:Interactional dilemmas and conversational consequences

Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care

The right to plan one’s future : Promotion of the right of self-determination when using continuing power of attorney

I denna uppsats undersöker jag om självbestämmanderätten främjas i största möjliga omfattning vid användning av framtidsfullmakter. Detta genom att belysa ett antal olika områden där det enligt min uppfattning kan ifrågasättas om självbestämmanderätten främjas. Vad jag har funnit är att självbestämmanderätten främjas i stor omfattning vid brukande av framtidsfullmakter, men att lagens utformning medför ett visst hämmande av den rättens genomslag. I flera fall kan hämmandet undvikas genom att fullmaktsgivaren utförligt utformar sin framtidsfullmakt. Om individen inte gör det kommer lagens utformning i flertalet fall att medföra att självbestämmanderätten inte främjas

The right to plan one’s future : Promotion of the right of self-determination when using continuing power of attorney

I denna uppsats undersöker jag om självbestämmanderätten främjas i största möjliga omfattning vid användning av framtidsfullmakter. Detta genom att belysa ett antal olika områden där det enligt min uppfattning kan ifrågasättas om självbestämmanderätten främjas. Vad jag har funnit är att självbestämmanderätten främjas i stor omfattning vid brukande av framtidsfullmakter, men att lagens utformning medför ett visst hämmande av den rättens genomslag. I flera fall kan hämmandet undvikas genom att fullmaktsgivaren utförligt utformar sin framtidsfullmakt. Om individen inte gör det kommer lagens utformning i flertalet fall att medföra att självbestämmanderätten inte främjas

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

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

Triage and patient satisfaction among callers in Swedish computer-supported telephone advice nursing Triage and patient satisfaction among callers in Swedish computer supported telephone advice nursing

Summary We investigated satisfaction with a Swedish telenursing service, and the healthcare seeking behaviour among callers who received a less urgent level of healthcare than they expected. A postal questionnaire was sent to a random selection of callers (n=273) to Swedish Healthcare Direct in October 2008. The "cases" were 18 callers where the telenurse recommended a lower level of health care than the caller expected and who were not in complete agreement with the nurse. The "controls" were 22 callers who either received a lower recommendation, or were in disagreement with the recommendation. There were no differences between cases, controls and other callers regarding background factors or the telenurse classification of emergency. However, both cases and controls considered their need for health care as more urgent than the other callers. An independent test of the nurses' reception, ability to listen and to take notice of the callers' health problem, showed that nurses who had served cases, had received a significantly lower rating than other nurses. For nurses who had served controls, there was no such difference in rating. Cases and controls had fewer subsequent care visits than other callers, in the three days following the call, although the proportion of emergency visits was higher among cases and controls compared to other callers. If the caller and the nurse disagree about the nurse's recommendations, the consequence can be a dissatisfied caller and more visits to unnecessary high levels of health care. Further training of the nurses may improve the telenurse service

Triage and patient satisfaction among callers in Swedish computer-supported telephone advice nursing

We investigated satisfaction with a Swedish telenursing service and the health-care-seeking behaviour among callers who received a less urgent level of health care than they expected. A postal questionnaire was sent to a random selection of callers (n = 273) to Swedish Healthcare Direct in October 2008. The cases were 18 callers where the telenurse recommended a lower level of health care than the caller expected and who were not in complete agreement with the nurse. The controls were 22 callers who either received a lower recommendation, or were in disagreement with the recommendation. There were no differences between cases, controls and other callers regarding background factors or the telenurse classification of emergency. However, both cases and controls considered their need for health care as more urgent than the other callers. An independent test of the nurses reception, ability to listen and to take notice of the callers health problem, showed that nurses who had served cases, had received a significantly lower rating than other nurses. For nurses who had served controls, there was no such difference in rating. Cases and controls had fewer subsequent care visits than other callers, in the three days following the call, although the proportion of emergency visits was higher among cases and controls compared to other callers. If the caller and the nurse disagree about the nurses recommendations, the consequence can be a dissatisfied caller and more visits to unnecessary high levels of health care. Further training of the nurses may improve the telenurse service.Funding Agencies|Swedish Research Council (Vetenskapsradet)||Faculty of Medicine, Uppsala University||County Council of Ostergotland|

Phenological changes of trees and scrub in Latvia

Bakalaura darba galvenais mērķis bija izanalizēt parastās ievas Padus racemosa ilgtermiņa tendences kopš 1927.gada, kā arī raksturot āra bērza Betula pendula, parastās lazdas Corylus avellana, baltalkšņa Alnus incana un parastā pīlādža Sorbus aucuparia pavasara fenoloģisko fāžu reģionālās izmaiņas Latvijā references periodā (1981.-2010.gads), izmantojot brīvprātīgo novērotāju vēsturiskos datus. Veikta digitālo fotoattēlu reģionāla analīze parastās ievas Padus racemosa fāzēm 2015. un 2016.gadā, izmantojot portāla Dabasdati.lv datu bāzi. Periodā no 1981.gada līdz 2010.gadam ir novērojams, ka pavasara fenoloģiskās fāzes iestājušās par 2-17 dienām agrāk, nekā laika posmā no 1971.-2000.gadam. Parastās ievas Padus racemosa pavasara fenoloģiskās fāzes visagrāk attīstās Latvijas piejūras un centrālajā daļā. Digitālie attēli ļauj veikt un izprast reģionālās atšķirības un raksturot fāzes iestāšanās laiku, kā arī fāzes norises intensitāti.The aim in Bachelor’s work was to analyse bird-cherry Padus racemosa long time tendencies since 1927 and to describe silver birch Betula pendula, common hazel Corylus avellana L., alder Alnus incana and rowan Sorbus aucuparia spring phenological phases regional changes in Latvia in reference period (1981 - 2010) using volunteer observers historical data. Done regional analyses from digital images about bird-cherry Padus racemosa phases in 2015 and 2016, using Dabasdati.lv database. In period from 1981 to 2010 is observed that spring phenological phases starts earlier from 2 to 17 days, than in period from 1971 to 2000. Bird-cherry Padus racemosa spring phenological phases first evolving in Latvia’s costal and central parts. Digital images allow to make and understand regional differences and describe phase onset time, and characterize phase intensity