Telephone counselling by nurses in Norwegian primary care out-of-hours services: a cross-sectional study

The primary care out-of-hours (OOH) services in Norway are characterized by high contact rates by telephone [1, 2]. Telephone contacts are handled by local emergency medical communication centres (LEMCs). The LEMCs are most commonly staffed by registered nurses, who triage the contacts and refer the patients to the appropriate level of care. If the patient’s condition does not require assessment by an on-call medical doctor, the nurse often handles the contact solely by telephone counselling. In most of the 200 or so Norwegian primary care OOH districts, the only way to contact the OOH services is by first calling the LEMC. In several of the largest cities patients can contact OOH casualty clinics at all times (24/7), and may turn up directly without calling the LEMC in advance. Direct attendance is, however, not encouraged. The OOH system is organized within the primary health care sector, owned by the municipalities, and serves as a gatekeeper to the hospitals and other secondary health care, which are owned by the state. Medical responsibility for the services is mainly assumed by general practitioners (GPs) who take shifts in their own OOH district, and by interns serving their compulsory general practice period.

Because of the challenging geography in parts of Norway, with poor roads, islands without road connection to the mainland, and scarcely-populated rural areas, the size of the OOH organisations varies considerably. The smallest organisation serves a population of less than a thousand people, while the largest casualty clinic in the capital, Oslo, serves more than 600,000.

The nurses’ contribution to the LEMCs constitutes an important part of the primary care OOH services. It is estimated that there were approximately 1.8 million contacts with the OOH services in Norway in 2013 (contact rate 0.36 per inhabitant per year) and about 75% of these contacts were telephone contacts to an LEMC (0.27 contacts per inhabitant per year) [2]. Based on estimates, less than a third of these contacts were handled solely by nurse telephone counselling, with a wide variation between the LEMCs [2]. Nevertheless, this is an important and large volume activity that educates and counsels patients and caregivers, and reduces casualty clinic workload.

Previous literature on nurses’ triage and telephone counselling in the OOH services has focused on the quality of communication and decisions [3‐7], the safety of telephone triage [8‐10], the use of protocols and decision support tools [11‐16], the process of giving advice over the telephone versus meeting the patient face-to-face [17], patients’ satisfaction with the advice, and their understanding and adherence to the advice [18‐21]. Overall, previous research has found nurse telephone triage to be safe [8, 21]. Nonetheless, the nature of telephone triage makes it a vulnerable part of the service because the patient is not seen face-to-face. The level of nurse telephone advice differs between countries, ranging from about 23% in Norway [2, 22] to 40–50% in the Netherlands and UK [18, 23]. Studies have found that the quality of the nurses’ advice is satisfactory [7], and that the patients understand and follow the advice given by the nurses [19‐21, 24].

Because the organisation of primary care services varies, it can be difficult to directly compare nurse telephone triage between countries. Many of the European countries have a strong primary care health service, where triage nurses cover the whole range of contact types. In countries where the primary care service is less built out, such as in the United States, additional nurse triage services are often run from the specialized health care services, aimed at specific patient groups, such as paediatrics [24‐26]. However, some findings are similar across continents. Studies from Europe, the United States, New Zealand and Australia all show that children constitute a large group of the OOH contacts across the different continents [2, 24, 27‐29]. Frequent RFEs in this group include fever, vomiting, colds and cough [24, 27, 28].

There is a lack of epidemiological studies documenting which medical problems and reason for encounter (RFE) are resolved and handled by nurses’ telephone advice in the OOH services. Some European studies include information on the RFE using the ICPC-2 classification system [29‐32]. In a Dutch study, researchers explored nurse telephone triage using the determinants of independent advice and return consultation [33]. Other than this, we have not found studies that investigate the characteristics of telephone contacts that were resolved by nurse telephone counselling.

Therefore, the present study aimed to identify which RFEs are most frequently handled by nurse telephone counselling in the OOH services. More specifically, we wanted to investigate which diagnostic chapters and single codes within the ICPC-2 are most frequently resolved by nurse telephone advice and, in addition, to examine a number of patient characteristics and the time of the encounter.

A cross-sectional design was applied to this study. Patient data for one year (2014) were collected from six OOH districts to estimate the incidence of nurse counselling at different RFEs.

The findings reveal that a large number of telephone contacts to the LEMCs were handled solely by nurse telephone counselling. The RFEs most frequently resolved by nurse telephone advice were fever, abdominal pain, cough, ear pain and general symptoms. Telephone contacts were more often resolved by nurse advice at night compared to day and evening, and more often during the week (Monday to Friday) compared to the weekends. A higher share of contacts with the youngest patients were handled by nurse telephone counselling compared with the oldest age group.

Of the total telephone contacts in our data material, 23% were handled solely by nurse counselling, which is equivalent to 65 nurse advice per 1000 inhabitants/year. This correlates with findings from previous years in the Watchtower project [2, 22]. It is also comparable with a study from the Netherlands where a nurse alone handled 27.5% of the telephone contacts [33]. Other studies from the Netherlands and UK have found that nurses handle as much as 40–50% of the contacts by nurse telephone advice [18, 23]. However, the literature seems somewhat divided on the effectiveness of nurse telephone triage. In one of the Dutch studies, it was indicated that high proportions of nurse telephone consultations were associated with increased probability of follow-up contacts, which in turn could lead to increased workload [18]. In contrast, studies from the UK found that nurse telephone consultation could reduce GP workload without an increase in adverse events [23]. Previous studies on the Norwegian OOH services conclude that two-thirds of the callers receiving nurse advice did not re-contact the OOH services, own GP or other sections of the healthcare services in the following week [19]. In the Norwegian OOH services, however, advising the patient to contact his or her own GP in practice hours is also an appropriate way of handling contacts that can wait. It is important to add that differences in the organization of the healthcare systems can make it difficult to directly compare study results between countries. In some European countries (e.g. UK and the Netherlands), and in the United States, self-referral to a hospital emergency department is possible. In Norway, a referral via the primary care sector is needed. Furthermore, in the Danish OOH service, it is mostly doctors who handle the phone calls, which is different from the other countries mentioned above, where nurses, physician assistants or secretaries handle the calls.

In our study, one fifth of all contacts handled by nurse telephone counselling were contacts regarding ICPC-2 chapter A (General and unspecified). The high frequency in this chapter can to some extent be explained by the code A03 (Fever). Fever was the symptom most often handled by nurse telephone counselling, and constituted 39% of all nurse advice given in chapter A. To the best of our knowledge, not many studies examine which RFEs telephone nurses resolve by advice. Findings from the United States also show that, among parents contacting a children’s careline regarding a child with fever, a majority followed nurse advice for home care, in spite of initially preferring to have their child seen by a medical doctor [25]. Furthermore, a Dutch study exploring determinants associated with nurse telephone advice alone presents similar findings to those found in our study [33]. A large share of contacts regarding earache, vomiting and fever were handled by nurse telephone consultations, consistent with our findings. Contacts regarding chest pain had the lowest share of nurse telephone advice, which is also similar to our study in which cardiovascular problems have the lowest share of contacts handled by nurse consultation. Furthermore, the Dutch study found that a greater share of telephone contacts was handled by nurse counselling at night, compared to day and evening. Contacts by the youngest age groups were more often handled by nurse advice compared to the older age groups. These findings are also in line with ours.

Several factors probably contribute to the large share of contacts handled in our study by nurse telephone counselling during the night, compared to day and evenings (Table 5); less resources at night-time, a desire not to wake the doctor on call, or the nurses may be stricter on what they would assign to be seen by a doctor during the night. Furthermore, our findings reveal that the major increase in nurse telephone advice during the night was due to changes in the two youngest age groups (Table 5). The lower share of nurse counselling during the weekend compared to the weekdays could be explained by the fact that it was not possible to advise the patients to contact their own GP the same day - or the day after, if a Saturday.

One reassuring finding is that the rate of nurse telephone advice declined as the patients’ age increased, indicating that nurses at the LEMCs make safe decisions. The oldest age group is a complex group, often presenting with several and more severe symptoms and comorbidities compared with younger patients. However, on our data form it is only possible to register one symptom per patient. Consequently, we do not know if the older patients in our group presented with a mix of symptoms. Another factor might be that contacts from the oldest age group were made much more frequently by health personnel on behalf of the patient. This means that the patient’s condition had often already been evaluated before contacting the OOH service. Furthermore, the youngest age group appeared to be more predictable regarding which RFEs the nurse resolved by nurse telephone advice. The five most commonly reported RFEs handled by nurse counselling in the youngest age group (fever, cough, ear pain, vomiting and localized rash), constituted around 40% of all advice given in this group. The type of contacts handled by nurse telephone counselling in the other age groups varied more.

Findings from Europe, the United States, New Zealand and Australia all show that children constitute a large group of the OOH contacts [2, 24, 27‐29]. Studies from Denmark, Scotland and the Netherlands also report that the youngest age group receives telephone advice more frequently than the older age groups [29, 33, 37], and involves symptoms similar to those found in our study [33]. In a study from England reporting on young people’s (aged 0–15) use of the telephone service NHS Direct, it was found that 44 to 49% of all calls were resolved solely by nurse advice [28]. The high share of nurse telephone counselling in this group of patients might emphasize the parents’ need for advice and reassurance when their children are ill. Measures to meet this need could include public health centres to provide information and guidance to parents on the most usual symptoms and conditions that affect infants and young children.

This study shows that nurses contribute significantly to patient management in the Norwegian OOH services. The findings can guide the process of developing training programmes for work in the LEMCs, especially in regard to the type of contacts the nurses have to manage and master. There is the potential for more nurse involvement in several of the RFEs which currently have a low share of nurse counselling. Finally, the study identifies areas that need further investigation. This includes the high share of nurse counselling provided during the night, compared to daytime, and the differences in the share of nurse advice between the youngest and the oldest age groups.