Telephone nurses’ experiences of managing callers affected by mental illness: A descriptive qualitative study

Abstract

Mental illness is a global health problem and encompasses many conditions with varying degrees of severity. Telephone contact is often the patient’s initial contact with the healthcare system. This study aimed to illuminate telenurses’ experiences of managing calls with patients affected by mental illness in primary healthcare. Semi-structured individual interviews were conducted with 11 telenurses and a qualitative content analysis was conducted. The COREQ checklist was used to ensure trustworthiness. The analysis revealed three themes, labelled as: ‘Finding a solution to solve and deal with circumstances’; ‘Being emotionally affected and re-evaluating the situation’; and ‘Using distracting approaches and creating space for reflection’. The results show that telenurses adopt different strategies to manage negative and positive situations. This requires telenurses to be adaptable with the patient affected by mental illness as well as within each call and the conditions within the healthcare organization to manage calls with patients affected by mental illness.

Introduction

Telephone triage, nurse advice and care management (henceforth ‘telenursing’) carried out by registered nurses (RNs) is a growing area in Sweden and in several other countries. ¹ Telenursing is a complex part of the healthcare system, as it is regarded as being qualified nursing care with demands on the telenurses’ knowledge and skills; as an example, their ability to listen and communicate.^2–4 In Sweden, telenursing can be carried out in diverse settings, for example, Swedish Healthcare Direct (SHD) call centres, primary healthcare and hospitals. Telephone contact is often the patient’s initial contact with the healthcare system, and telenurses talk to people of all ages with a wide variety of health problems. ⁴ Several factors have been found that might affect telenurses, and these can disturb their encounter with patients, such as their work environment, demanding callers, and difficult calls.^5–7 Encountering patients affected by mental illness in telephone counselling can be experienced as demanding for telenurses, due to the patients’ presentation of sometimes diffuse symptoms, experiences of lack of adequate help, time-consuming encounters, and the limitations of computerized decision support systems (CDSS). ⁸ Today, mental illness is increasing in Swedish society, yet little focus has been placed on how telenurses manage calls that relate to those affected by mental illness.

Background

In Sweden, primary healthcare is available via telephone on work days between the hours of 08:00 and 17:00, and the national telephone helpline for healthcare, the SHD, is available 24 hours a day and seven days a week. ⁹ Registered nurses working as telenurses in primary healthcare settings in Sweden have often completed a specialist nurse education programme which acts as a resource in their daily work. The most common is specialist education as a primary healthcare nurse. In Sweden, similar to nursing standards in many other countries, specialist nurses are certified and have a second-cycle level of higher education, including a master’s degree. The specialist nurse education programmes place an emphasis on critical thinking, research, and ethics in both theoretical and clinical aspects , ¹⁰ which can lead to improved personal confidence, enhanced cognitive functioning, evidence-based practice development, and increased professionalism. ¹¹ Telenurses’ caring competence is the basis for providing person-centred care when telenurses communicate with the callers to gather information. ¹²

In Sweden, telenurses have received about two to three weeks of theoretical education in the course of their nursing education, and between one and five weeks of praxis that focuses on mental illness. Furthermore, in specialist education for primary healthcare nurses a small thread of focus on mental illness runs through some courses in the programme. Earlier research reports that primary healthcare nurses lack knowledge and skills to encounter patients with mental illness. ¹³ Furthermore, they also conclude that even if the primary healthcare nurses were interested in developing their understanding and skills for taking care of patents with mental illness few of the nurses had received training for improving their skills. Kerrison and Chapman ¹⁴ describes that nurses with limited psychiatric knowledge and little training to take care of patients with mental illness can lack skills to provide good care to patients with psychiatric illness.

Telenurses usually work at a computer wearing a headset and managing a constant flow of unsorted, incoming calls. ¹⁵ Telenurses in Sweden have access to specialized resources, such as a computerized decision support system (CDSS), which contains medical quality assured decision-making databases, which are structured on symptoms and with five grades of emergency. In the CDSS they can search for symptoms such as, for example, worry and anxiety, and get support on how to ask questions, as well as links with information about patient associations and websites focussing on, for example, crisis and grief support. The main focus of the CDSS is on somatic symptoms of illness, and useful telenurses have previously expressed that the system is supportive, but can also obstruct their practice when the assessment made by the CDSS does not align with their own professional opinion. ¹⁶

Communication is an essential foundation of telenursing and places great demands on telenurses to interact with and assess the callers’ health problems. This process implies a lack of visual contact with the callers and takes place in a non-physical care setting, which is challenging for the telenurses. ¹⁷ In addition, sometimes it is not the patient who calls; instead, it can be a relative, who may complicate the telephone assessment and can act as an unreliable source for assessing the level of care needed. ¹⁸

Telenurses manage calls from persons affected by mental illness every day, ⁸ as well as recurrently. ¹⁹ The national primary healthcare remit includes the assessment of patients affected by little to moderate depression, anxiety disorders, stress-related conditions, and crises and psychosomatic conditions. ²⁰ Reilly et al. ²¹ report that continuity in primary healthcare is crucial for persons affected by mental illness, but, because collaboration with other caregivers is also essential, mental healthcare must find new ways of working. Previous research describing telenurses’ experiences of such calls reports how persons affected by mental illness are perceived by telenurses as being fragile; they therefore have to adjust and adapt, while having little control of the situation. ²² Furthermore, previous studies report that staff in somatic care perceive patients who are affected by mental illness as being more scary, unpredictable, and demanding than other patients.^8,23,24

Mental illness is a global health problem for adolescents and adults.^25,26 The concept of mental illness encompasses many conditions, with varying degrees of severity, ranging from occasional milder symptoms to serious mental disorders. Mental illness can be regarded as an overall term which embraces a wide range of conditions where depression is the most common diagnosis. Depression, anxiety syndrome, and stress-related problems are frequent reasons for sick leave in Sweden, especially among women. ²⁷ Mental illness can be regarded as a subjective experience based on each individual, and, when an imbalance occurs between the individuals’ resources and external demands, the individual may experience mental illness. ²⁸

Globally, one billion people, about 14% of the earth’s population, suffer from mental illness, ²⁹ including over one-third of the EU population during any given 12-month period. ³⁰ However, the number of individuals suffering from mental illness varies from country to country. In Sweden, 17% of the population aged 16–84 years stated that they are affected by mental illness, with higher proportions of women than men, and more younger people than older people. Mental illness is described as being more frequent among individuals born outside of Europe, compared with individuals born in Sweden. ²⁷ Patients affected by mental illness can experience discrimination, which can arise from not being offered the same attention and treatment in caring settings as patients who are not affected by mental illness. ³¹

In general, and depending on the context and the individual’s appraisal of the situation, when faced with certain challenges, a person chooses a strategy to follow. The individual makes an appraisal to evaluate their resources and ability to deal with such challenging and often stressful situations. A previous study shows that telenurses regulate stressful demands by developing and applying their emotional intelligence. ³² This could be seen as a strategy that provides telenurses with the ability to recognize their own and the caller’s emotions that arise in complex and difficult calls. In order to understand how telenurses manage calls with patients affected by mental illness, more knowledge is needed. Therefore, the aim of this study was to illuminate telenurses’ experiences of managing calls with patients affected by mental illness in primary healthcare.

Methods

Design

A qualitative approach with a descriptive design was applied, and semi-structured individual interviews were conducted with 11 telenurses to obtain detailed narratives. The analysis followed Graneheim and Lundman’s ³³ description of inductive qualitative content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to assure quality. ³⁴

Sample and recruitment

In this study, a sample of 11 telenurses from six Primary Health Care Centres (PHCCs) in western Sweden participated. In total, ten PHCCs were invited, and, of these, six were interested in participating. Participants were recruited with help provided by the directors of these six PHCCs, who sent written information about the study to their telenurses. Registered nurses who worked with telephone triage, advice nursing and care management who were willing to participate contacted the authors (Author 3 or Author 4). They were given additional verbal information about the aim of the study and were asked to participate in an interview. The telenurses who participated were all women, had completed a specialist education programme in primary healthcare nursing, a second-cycle level of higher education, including a master’s degree, and had between six months and 29 years of experience working in counselling via telephone in a PHCC.

Data collection

Qualitative and semi-structured individual interviews ³⁵ were used to allow the telenurses to describe their experiences from their ordinary workday of counselling by telephone with patients affected by mental illness. An interview guide was designed and tested in one pilot interview. The interviews started with the question: ‘In telephone counselling, tell me about how you manage calls with patients suffering from mental illness?’ This was supplemented by follow-up questions, for example: ‘Can you tell me more about that?’ or ‘What do you mean?’, which were used for encouraging participants to reflect and further illuminate their narratives.

The interviews were conducted during the spring of 2018 by the authors (Author 3 and Author 4). The dates and times for the interviews were determined in mutual consensus and all were carried out in private rooms at the participants’ workplaces. The interviews lasted between 30 and 45 minutes, were audio-recorded and transcribed verbatim.

Data analysis

A qualitative content analysis was performed.^33,36 First, the data material was read several times by all authors to certify that each obtained a clear grasp of the total content and to provide an opportunity for preliminary reflection on the data material. Then, meaning units that related to the aim of the study were identified, and were further condensed by altering the telenurses’ expressions into summarized statements and labelling these with a code. Codes with similar meanings, or which related to similar matters, were gathered into subthemes. The subthemes were given a descriptive name. The subthemes with comparable meanings were then gathered into three themes. Finally, the three themes were named with content-representative words that illuminated telenurses’ experiences of managing calls with patients affected by mental illness in primary healthcare. To enhance trustworthiness, the five authors contributed throughout the whole analysis process and discussed the findings together. The analysis followed an iterative process, characterized by going back and forth between the whole and parts of the text.

Ethical considerations

This study followed ethical regulations and principles and conforms to the Declaration of Helsinki. ³⁷ According to Swedish legislation, ethical approval was not needed for this study. Written informed consent was obtained from all participants.

Results

The qualitative content analysis of the data material resulted in three themes: ‘Finding a solution to solve and deal with circumstances’; ‘Being emotionally affected and re-evaluating the situation’; and ‘Using distracting approaches and creating space for reflection’. The themes are described in detail below and, to exemplify the findings, quotations from the interviews are used.

Finding a solution to solve and deal with circumstances

The telenurses described how they focus on how to solve the situation and promote the patient’s mental health. They focused on strategies that could solve the circumstances over time with a long-term perspective. They described how they try to manage telephone counselling by adopting a problem-focused strategy. The telenurses manage the calls on the basis of several possible solutions, for example, booking follow-up appointments while waiting for an appointment with a physician or a counsellor. Even if telenurses did find solutions in the moment, they often continued to think about callers’ expectations and whether the callers felt that they had received adequate help.

I worry about the patient’s expectations … there is often a lot to sort out, consult, call and fix. (Interview 5)

The telenurses described how they try to create an overall picture of the caller’s situation, based on the patient’s narrative. This could sometimes be difficult in telephone counselling, where they are unable to read the caller’s body language and facial gestures. This creates worries among telenurses that they may miss important information. To deal with this, the telenurses described how they develop a sensitivity in reading the conversation in order to be able to listen and interpret how callers perceive and describe their situation and symptoms. They give callers space and time to share their condition by listening to the caller’s narrative as a strategy to find a solution for their symptoms of mental illness.

It is important to let the patient have space to tell, and let the conversation take time and listen for an extra moment and take those extra minutes. (Interview 11)

The telenurses experienced that it is important to show interest in callers’ narratives and involve the callers in the conversation as a strategy for creating an alliance between the nurse and the caller. The telenurses described that, when callers feel confident and reassured that they will receive help, they accept having to wait a few weeks for an appointment with a counsellor or a physician.

… self-determination is an important part of care, because then the patient feels they are in focus. (Interview 4)

For telenurses, one strategy they described is to focus on creating security and trust in the conversation as a part of trying to calm patients, who often express feelings of hopelessness and loneliness in their situation. To deal with the situation the telenurses endeavour to create and give the patient hope for the future.

… against all odds maybe I can give someone hope … (Interview 7)

Another strategy that the telenurses described to deal with circumstances was to create space during the day for recovery from stress – they seize opportunities during the day to talk to colleagues. They stressed that sharing experiences from telephone counselling with colleagues and giving each other support and feedback is important for their wellbeing and professional identity. Using this kind of strategy allows them to focus on the problem that causes stress at work, both in the moment and also in the long-term.

Conversations that can be more structured or during a break or meeting. It is important to have the opportunity to talk about telephone counselling [calls] that are perceived as heavy. (Interview 10)

Being emotionally affected and re-evaluating the situation

The telenurses described how they use emotion-based strategies to minimize their own stress, which they may experience during or after telephone counselling sessions with patients affected by mental illness. Telephone counselling requires that telenurses are open to receiving the patient’s narrative, which requires courage and readiness. Sometimes, telenurses become emotionally affected by the patient’s narratives about tragic and upsetting life events that depend on or are created by long-term symptoms of mental illness. Such narratives can sometimes be difficult to let go of, which telenurses described as affecting their leisure time and which could lead to illness as well as sleep disturbance and anxiety. The telenurses described how they use emotional strategies such as re-evaluation of the situation as a way in which they manage their own stress. They also described feelings of inadequacy and frustration with the healthcare system, which is not able to provide adequate care for patients affected by mental illness.

The conversations feel difficult and sometimes uncomfortable … and afterwards it often feels like I not have done enough and it is a shitty feeling. (Interview 1)

Conversations could also create feelings of inadequacy, grounded in telenurses’ lack of knowledge about how to manage and support patients with symptoms of mental illness. The telenurses described how they endeavour to find strategies for dealing with both their own and their colleagues’ frustration, linked to lack of knowledge, by trying to navigate through the conversation and occasionally using CDSS. The telenurses described how they experienced the CDSS as sometimes being insufficient, which creates stress among telenurses. They described feelings of anxiety about making incorrect assessments and giving incorrect advice that could aggravate a caller’s situation.

I feel that I have not enough knowledge to support them in the conversation … do not dare to give advice as I am afraid to be wrong. (Interview 6)

Telenurses described how they have to trust and sometimes re-evaluate their own knowledge and competence, even if they often reflect on their lack of conversational methodology and counselling regarding symptoms of mental illness. To manage with this, the telenurses use their medical knowledge and previous experiences from their professional or private lives. They also described experiences of emotional strategies that they had previously used to manage difficulties or illness. They described wishing that they had greater evidence-based knowledge about mental illness, both medically and in terms of nursing practice.

I use my medical knowledge, experience and common sense … sometimes I cry because none of this is enough. (Interview 7)

The telenurses described that sometimes feelings of anxiety and compassion for the patient arise, which they often manage by calling the patient at the end of the work day to confirm that everything is ok. For the telenurses, it is important to obtain confirmation that they have made the correct assessment and to feel satisfied after the counselling session that they have been able to provide callers with sufficient support and help.

When you can feel satisfied after the call if you feel that the patient is satisfied when you hang up. That you have succeeded. It’s a good feeling. (Interview 2)

Using distracting approaches and creating space for reflection

The telenurses described how they use distracting approaches and create space for reflection to manage counselling patients affected by mental illness. Such approaches seem to help the telenurses to distance themselves from the patients’ narratives – narratives that require concentration and being able to focus on the underlying messages that the callers convey. When the telenurses feel that they do not have enough energy, for example, after a period of higher workload, they described being able to choose to hand over the responsibility temporarily to a colleague. They know that this strategy is a temporary solution and that no solution is long-term.

It sounds awful but I just want to get it out into the world for the day … to solve it for the moment and hope it calms down for the patient. I hope that someone else will solve the problem. (Interview 3)

The telenurses described how they could ask the patient to pause the conversation, in order to give them space to reflect and find a solution for how they might support the patient. This space for reflection is an important part of creating a distance from the patient’s narrative and for creating an overall picture of the patient’s health. To use this kind of avoidance strategy provides space to find and bring energy into the counselling session.

The telenurses experienced that recall from callers week after week, could be stressful and sometimes, due to lack of time, the telenurses avoided starting a deeper conversation with the caller in the hope that the caller would choose to contact a different care provider. This is because telenurses know that they do not have enough time or resources to adequately support patients affected by symptoms of mental illness.

We have very long queues here and then you do not have sufficient resources, because then you would not have a queue. (Interview 1)

To manage the situation, the telenurses choose to position the circumstances outside themselves and situate them within an increasing public health problem and a lack of resources within the organization. The issue is thus framed as being based on political decisions for which the telenurses are unable to take responsibility. The telenurses described how they are forced to use strategies that are about avoiding reflecting on their working conditions, and sometimes they take a negative attitude towards callers with symptoms of mental illness as a way of transferring the responsibility to the patients.

Discussion

The aim of the study was to illuminate telenurses’ experiences of managing calls with patients affected by mental illness in primary healthcare. Their experiences are grouped into three themes: ‘Finding a solution to solve and deal with circumstances’, ‘Being emotionally affected and re-evaluating the situation’, and ‘Using distracting approaches and creating space for reflection’. To find solutions to solve and deal with circumstances applies to the telenurses, as these seem to be strategies that they used to work in a more problem-focused way. The patients’ own expectations of the call are often to get an appointment with a physician or counsellor; an expectation that cannot always be met due to a lack of available appointments. To manage this, the telenurses instead try to find alternatives, such as making follow-up telephone calls themselves. This can mean that telenurses feel like gatekeepers, due to limitations in the healthcare services and because the patients are not able to get the help that they actually need and expect, which can be experienced as stressful for telenurses.^7,38 The telenurses also described the importance of being sensitive and present in the call, for example, asking open-ended questions. In contrast, the use of CDSS does not facilitate this fully, because this system is mainly medically focused and is limited regarding information about mental illness and mental health. ¹⁶ There is also a risk that telenurses may become passive when they work with a CDSS and feel as though they are being controlled.

The telenurses also described that they need to create an overall picture of the patient, which can be difficult in telenursing, as they do not see the patient and cannot interpret the patient’s body language and facial expressions. This can create feelings of uncertainty in the telenurses, and the worry of missing important information. ⁷

One of the themes shows that telenurses can be emotionally affected, which they may experience during or after the call, and which could be prompted by their re-evaluation of the callers’ narratives. This can be related to a perceived lack of knowledge of mental illnesses, a notion which is confirmed by Björkman and Salzmann-Erikson ¹⁹ as well as by Haddad et al. ¹³ They describe that a lack of knowledge and experience can be regarded as a hindrance for providing good care. In the present study, all the telenurses had completed specialist education in primary health nursing and had experience in telenursing. Despite this, they expressed a lack of knowledge, which highlights the need for including appropriate content regarding mental illnesses in nursing education or in specialist master’s degree programmes. In addition, telenurses can refresh and develop their knowledge related to mental health and illness during working hours. ³⁹ The telenurses in this study also described that they often become emotionally affected by the patients’ narratives and that it might be difficult to let go after they have finished their work. A previous study shows that reflection seems to be especially important when managing difficult calls, as this kind of call can be emotionally draining. ⁷ It is also well-known that reflection enables nurses to support the patient more effectively and to have a more prominent role, despite a lack of resources and a high workload. ⁴⁰

This study shows that the telenurses sometimes use distracting approaches to manage calls and to counsel patients affected by mental illness. The telenurses distanced themselves from the patients’ narratives by using strategies that seem distracting; for example, they might hand over responsibility temporarily to a colleague or avoid starting a deeper conversation with the caller, and they could also request that the patient waits while they pause the conversation. Recent research has shown that making a pause in the call can be a strategy that allows telenurses to reflect on and discuss the situation with colleagues, which can be a way for telenurses to find the strength to manage difficult calls. ³²

Different strategies were adopted by the telenurses to assess the situation. They used emotion-focused strategies and avoidance strategies in uncontrolled situations, and problem-focused strategies in situations over which they felt they had control. Often, people use all strategies available to them in a stressful situation. ⁴¹ According to a recent review, nursing practice is challenged by organizational structures and the development of the healthcare system, which inhibits nurses’ professional decision-making and sometimes forces them to compromise on fundamental nursing values. ⁴² The telenurses in this study used emotion-based strategies to minimize their own distress during or after telephone counselling sessions. They must also seek a balance when they are forced to provide actions that conflict with their own professional convictions and values. The telenurses want to help patients with symptoms of mental illness, to find a solution that helps the patients to feel hope and trust. However, the telenurses described a lack of resources and that this caused feelings of inadequacy and mental stress/distress. Previous research has found that moral distress is associated with perceived poor ethical climate, such as lack of support in dealing with trying patients, and moral distress was associated with decreased job satisfaction and burnout. ⁴³ Moral distress arises from problems within organizations, such as ineffective team communication, policies or procedures that offer insufficient guidance, and unaddressed staffing shortages. ⁴⁴ According to Haarh et al., ⁴² this is common among nurses, due to the rigidity of organizational structures. Our findings suggest that, while the participants did experience moral distress relating to organizational elements, they often sought effective strategies to cope with these feelings, such as communicating with their peers.

Limitations

This qualitative study includes a small sample from one geographical location, the participants were recruited with help provided by the directors of the PHCC, and all participants were women, which could have affected the study results and may present a limitation. Some of the interviews were short and some participants had a short amount of work experience – six months of telenursing – which may also be a limitation. Still, all of the interviews were rich in description of how telenurses manage calls with patients affected by mental illness in primary healthcare. Among the research group, there were different experiences in telephone counselling; two of the researchers have experience in primary healthcare, and one researcher in psychiatry care. To strengthen the objectiveness of the study, all authors discussed the steps taken during the research process to reach consensus. ³⁶ In qualitative studies the researchers are the instrument, which points toward that fact that the researchers’ competence and their development of self-awareness is essential for promoting thoroughness and integrity in evaluating the findings. ⁴⁵ The extent to which the results can be generalized to another population must be decided by the reader.

Conclusion

This study reveals the importance for telenurses working in telephone counselling of having a number of different strategies to support and manage patients affected by mental illness in a satisfactory and safe manner. This requires that telenurses be adaptable with the patient as well as within the call and the conditions within the healthcare organization. Since lack of knowledge and experience can be perceived as a hindrance for providing good and safe care, it is important that the telenurses have enough knowledge and skills to make correct assessments and provide adequate advice. For example, it is essential that the CDSS is developed to include knowledge about mental illness. Due to the complexity of managing with such situations, it is essential for telenurses to have opportunities for reflection so they can be supported by each other. This suggests that the healthcare organization should ensure that telenurses are provided with the conditions to facilitate both reflection and opportunities to develop their knowledge.

Relevance for clinical practice

Telenurses who manage calls from patients affected by mental illness need space for reflection to support each other as well as to increase their knowledge to allow them to manage these patients’ needs. Furthermore, collaboration with other caregivers who have responsibility for providing mental healthcare seems to be essential in enabling telenurses to develop knowledge and become familiar with the healthcare organization so that they can effectively manage calls from patients affected by mental illness. It is important that research in all three areas (reflection, knowledge, collaboration) is developed to support patients with mental illness as well as telenurses’ own mental health. In addition, the CDSS must be further developed to adapt to this particular patient group.