Malpractice claims in Swedish telenursing: lessons learned from interviews with telenurses and managers.

Malpractice Claims in Swedish Telenursing Lessons Learned From Interviews With Telenurses and Managers Marta Röing ▼ Inger K. Holmström

Background: This study deals with serious malpractice claims within Swedish Healthcare Direct, the national telephone helpline in Sweden. At least 33 claims of malpractice have been filed since the service was created in 2003. Although a low number, consequences have been tragic. Research in Swedish telenursing on contributing systemic and organizational factors and consequences of malpractice claims is sparse. Objective: The objective was to explore the direct experience of telenurses’ and call center managers’ involvement in actual malpractice claims—with focus on factors that may have contributed to the claims—and on the consequences of the claims. Methods: Six telenurses and five managers agreed to participate in open-ended interviews. A directed content analysis approach was chosen to analyze the transcribed interview texts. Results: Stress, shiftwork, fatigue, multitasking, understaffing, and factors embedded in the system could have contributed to the malpractice claims. Safety management was treated locally, with no attempts at organizational reforms. Discussion: The solitary nature of the telenursing task emphasizes the importance of an organization, which works toward providing an environment where telenurses can feel safe and supported. This may require, in turn, a change in both organizational and professional attitudes toward safety and risk of error. The greatest hinder may be healthcare providers themselves. If the difficulties in recruiting participants for this study are any indication, reaching out to healthcare providers who remain silent may be the greatest challenge. Key Words: directed content analysis malpractice Sweden telenursing Nursing Research, January/February 2015, Vol 64, No 1, 35–43

H

ealthcare providers are not infallible, and they can make errors, which can lead to malpractice claims (Leape, 1994). In these situations, errors are defined as “the failure of planned actions to achieve their desired goal” (Reason, 2005). They can be classified as slips (often caused by heavy workloads) or mistakes/lapses (caused by incorrect choice) and can be either preventable or nonpreventable (Leape, 1994; Reason, 2005). This study enquires into serious medical malpractice claims within the context of a relatively new healthcare service in Sweden, the national telephone helpline: Swedish Healthcare Direct (SHD). This service was created in 2003 to increase patients’ access to healthcare services, make the use of healthcare services more effective, and enhance patient safety (Swedin, 2003). Thirty-three malpractice claims arising from calls to the service have been filed during the period between 2003 and 2010. Among these, 13 patients died, and 12 were admitted to an intensive care unit (Ernesäter, 2012). Marta Röing, PhD, is Researcher, Department of Public Health and Caring Sciences, Health Services Research, University of Uppsala, Sweden.

Inger K. Holmström, PhD, RN, is Professor, School of Health, Division of Caring Sciences, Care and Social Welfare, Ma¨lardalen University, Va¨stera˚s, Sweden. DOI: 10.1097/NNR.0000000000000063 Nursing Research

Medical malpractice systems differ around the world. Sweden, Denmark, Finland, and New Zealand have a no-fault medical malpractice system, which differs in many ways from the tort litigation system adopted in the United States (Studdert & Brennan, 2001). The tort litigation system is a fault-based model where patients are compensated when they can prove fault or negligence on the part of the healthcare provider (Studdert & Brennan, 2001). The no-fault system in Sweden allows patients to be compensated without proof of providers’ fault or negligence. However, only avoidable injuries are compensated (Studdert & Brennan, 2001). Swedish patients who believe they have been injured as a result of medical care apply for compensation to a special Patient Claims Panel, which then issues advisory opinions as to compensation (Johansson, 2010). Because county councils in Sweden are responsible for medical services, they are usually the target of compensation claims. They are required to carry patient insurance that covers compensation for injuries, and it is this insurance that compensates the patients (Johansson, 2010). Sweden also has a self-reporting system for serious medical errors, which exists side by side with the no-fault system for patient compensation (Odegård, 1999). Healthcare providers are required by law to report medical malpractice to the National Board of Health and Welfare (NBHW), the supervisory authority www.nursingresearchonline.com

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

35

36

Lessons Learned From Malpractice Claims

responsible for the promotion of patient safety, prevention of injuries, and reduction of risks associated with healthcare services (Socialstyrelsens författningssamling, 2005, p. 28). The NBHW is not associated in any way with patient insurance or compensation. Instead, it administers and investigates the claims and recommends actions/changes to be taken by healthcare organization managers, or disciplinary measures, if necessary, for any healthcare providers involved. The number of serious malpractice claims in Sweden has steadily increased during the past 10 years, with 2,143 claims reported in 2012 (NBHW, 2013). These claims have included death or serious injury because of lack of safety precautions during treatment, medication errors, delayed or incorrect treatment or diagnosis, incidents related to poor work practice, and hospital-acquired infections (NBHW, 2013). In recent years, NBHW investigations of malpractice claims have begun to take a “systems” approach, searching for possible causal factors embedded in the whole system, instead of the “person” approach, with its single focus on active failures of healthcare providers (Sveriges Riksdag, 2010). More consideration is given to sources of error at the “blunt end” of the healthcare system (systemic and organizational sources) rather than only the “sharp end”—the healthcare providers in direct contact with patients (Nolan, 2000; Reason, 2000). This is in keeping with the human error theory on patient safety, which states that situations—rather than individuals—are error prone (Armitage, 2009). Thus, human error does not have to be a question of medical (in)competence but can be a symptom of trouble deeper inside the system (Dekker, 2011, p. 41). It can be systematically connected to features of healthcare providers’ tools or equipment, tasks, workspace, environment, and organization (Dekker, 2011, pp. 41–42; Norris, 2009) as well as interaction with patients. All these factors then need to be considered in the investigation of malpractice claims and, even more importantly, when recommending designs for safe systems in healthcare (Nolan, 2000; Norris, 2009). Another factor to be considered in the investigation of medical error is the safety culture of an organization, that is, how it responds to problems and errors. Three different cultures of safety have been differentiated—pathological, bureaucratic, and generative—based on the way the organization handles safety-related information (Westrum, 2004). A generative culture has an open climate and open communication about safety—with everybody learning from the experiences of others—good or bad (Parker, 2009; Westrum, 2004). In a bureaucratic culture, safety management is most often treated locally, with no attempts at systemic reforms, and in a pathological culture, focus is on covering up failures and finding a scapegoat (Parker, 2009; Westrum, 2004). Research on safety in Swedish telenursing thus far has focused on the “sharp end” of the telenursing system, the encounter between telenurses and callers (Ernesäter, Winblad, Engström, & Holmström, 2012; Röing, Rosenqvist, & Holmström,

www.nursingresearchonline.com

2013), although research on the “blunt end” of telenursing services—the system and organization—is sparse. This study explores the direct experience of telenurses’ and call center managers’ involvement in actual malpractice claims. This insight, as a starting point, may add to knowledge, first, about what may be embedded in the present telenursing system that allows serious incidents to occur and, second, how the system responds to error. This knowledge may be used thereafter to prevent error and identify requirements for a safer telenursing system.

METHODS Design A qualitative descriptive design was chosen for this study. Interviews were used to explore the thoughts, feelings, and experiences of the telenurses and managers.

Setting: Telenursing in Sweden Telenursing is being practiced in many Western countries. It has been recognized as a distinct practice in nursing since the 1960s in the United States and Sweden, 1970s in Canada, and the 1990s in the United Kingdom (Leppänen, 2008; Rutenberg & Greenberg, 2012).The structure of the Swedish telenursing service is very similar to National Health Service Direct in the United Kingdom, and it has been stated that, to some degree, National Health Service direct has been a background model for the planning of SHD ( Smith, Valssechi, Andersson, & Sederblad, 2012). SHD is a network of call center sites connecting all of Sweden’s 21 county councils and regions (1177 Vårdguiden, 2014). The service is reached via one telephone number, 1177, from anywhere in the country, 24 hours a day. Calls are answered directly by 1,100 telenurses working at 33 call center sites, managed by 23 operative managers. The call center sites in Sweden may be working places for 5–70 telenurses (Kaminsky, 2013) who provide telephone nursing that focuses on “assessment, prioritization, and referral to appropriate levels of care” and “identifying the nature and urgency” of callers’ needs (American Academy of Ambulatory Care Nursing, 2007). They do not attempt to make diagnoses. They can give self-care advice, suggest the caller to contact a primary health clinic, or order an ambulance to transport a caller to the hospital emergency department (Röing, Rosenqvist & Holmström, 2013). An average of 5.5 million calls are received yearly (1177 Vårdguiden, 2014). As yet, telenursing is not a nursing specialty, nor is there an explicit description of the work task (Kaminsky, 2013). Instead, the telenurses use their previous nursing experience and clinical knowledge together with a computerized Decision Support Tool (DST), which is a requirement. All telenurses are trained to follow the same specific dialogue process when communicating with callers (Runius, 2008). Two to four


Nursing Research • January/February 2015 • Volume 64 • No. 1

telenurses may work together in rooms or cubicles, depending on the size of the work force. They communicate with callers via telephone headsets while sitting sit in front of computers, which monitor, document, and audio record the calls and provide call statistics (e.g., calls waiting, length of each call, or time between calls) (Ernesäter, 2012; Kaminsky, 2013). At many call centers, telenurses are advised to reply to six to eight calls per hour (Kaminsky, 2013). They bear professional responsibility for their assessment and advice to callers and, at worst, can lose their license in case of serious error. Most call center managers have nursing backgrounds. They lead, support, and monitor telenurses in the delivery of telenursing services and are responsible for implementation of policies, goals, budgets, hiring of personnel, and quality and patient safety measures (Kaminsky, 2013). Medical doctors are also adjoined to some call center sites. They are formally responsible for the medical setting, work together with managers in the implementation of quality and patient safety measures, and are always involved in preliminary investigations of any incidents that might lead to malpractice claim.

Context: Malpractice Claims in Swedish Telenursing Forty-five calls resulting in the 33 malpractice claims mentioned in the introduction were analyzed and presented in a recent study by Ernesäter (2012). The calls were made by 19 male and 24 female callers (some callers had called more than once), with abdominal pain and chest pain as the most common reason for calling. Thirteen patients died, 12 were admitted to an intensive care unit, seven were admitted for standard care for more than 24 hours, and one left the hospital after medical treatment. Sources of error at the sharp end, according to the NBWH investigation, included failure to listen to the caller, communication failure, and asking too few questions (inadequate anamnesis). Sources at the blunt end, again according to the investigation, included deficit DST, high workload, and lack of personal competence/inadequate introduction to work. As a result of the investigation, measures reportedly taken at the call centers involved included discussions in work group, education of staff, revisions of guidelines, and DST. Two telenurses were discharged (Ernesäter, 2012).

Participants All 23 call center managers in Sweden were contacted by mail and informed about the overall purpose of the study. Those interested in participating were asked to reply via email, after which they could arrange an interview with the first author. Because of the sensitive nature of the study, the ethics committee stipulated that recruitment of the telenurses should be made only via the managers. The letter to each manager, therefore, contained several copies of information for the manager to pass on to telenurses at the call center sites who had been involved in malpractice claims. Telenurses interested in


37

participating were asked to send back a signed consent form, in which they agreed to participate, to the first author and, at the same time, give the first author an email address or telephone number where they could be reached to arrange for date, time, and place for an interview, as with the managers. After one reminder to the managers, five managers and six telenurses agreed to participate. The nurses ranged in age from 42 to 62 years. They had 9–33 years of nursing experience in a wide variety of specialities, and 3.5–12 years (M = 8 years) of telenursing experience. The managers were 40–64 years old and all women and had 3–15 years of management experience (M = 11 years).

Data Collection The participants were interviewed by the first author from March to June 2013. All interviews were confidential. In situations where participants worked at the same call center, managers were not informed of any telenurses who had agreed to participate, and telenurses were not informed about interviews with colleagues or their managers. The interviews began with questions regarding previous working experience. As the interviewer had no previous knowledge about specific malpractice claims and their outcomes, both managers and telenurses were asked the same first question: to describe an incident that had led to a malpractice claim. No attempts were made to discuss fault or error. Instead, based on the context of these descriptions, the participants were asked to reflect on any factors that they felt may have contributed to the incident that led to the claim. The interview continued with questions regarding the consequences of the malpractice claims, lessons learned, and changes made at the work place as a result of the claim. The interviews lasted 60–90 minutes. They were recorded, transcribed verbatim, and then processed as texts.

Ethical Considerations This study was approved by the regional ethics committee. The interviewees were guaranteed confidentiality and informed that they were at liberty to abstain from participating and were free to withdraw from the study at any time. Written consent was obtained from all the telenurses. Because the interview questions involved perhaps difficult experiences, every interview was concluded by asking the informants how they had experienced the interview. In this way, they were given an opportunity to reflect on their answers and deal with any unexpected thoughts that might have been awakened during the interview. This question was answered with positive comments by all participants.

Data Analysis A directed content analysis approach to the transcribed interview texts was chosen. This approach is more structured than conventional content analysis and is appropriate when prior


38



research about a phenomenon would benefit from further description or to validate a theoretical framework (Hsieh & Shannon, 2005). In this study, prior research regarding the connection between error and features in the telenursing system is incomplete and in need of further exploration. The transcribed interview texts were read thoroughly by both authors. The participants’ thoughts and reflections on the two main areas of interest in this study, contributing factors, and consequences of malpractice claims served as a coding framework. Significant texts or meaning units related to these areas were identified and coded in each interview (Table 1). The codes from all the interviews were then compared for similarities and differences and further sorted and differentiated under these two main domains. The analysis was conducted by the first author—with the second author acting as co-reader—and was also discussed in a research group seminar. Translation of the responses from Swedish to English occurred after the analysis, in connection with the writing of the manuscript.

RESULTS The responses of the managers and telenurses are presented separately, reflecting their different perspectives, under two main domains: (a) factors that may have contributed to incidents, which led to the malpractice claim; and (b) consequences of the malpractice claims. The domains and categories, together with their subcategories, are presented in Table 2. A description of each category illustrated by quotations from the interviews follows.

Telenursing in Sweden: Possible Factors Contributing to Errors Telenurses When reflecting on possible factors contributing to incidents that had led to the malpractice claims, the telenurses focused on the work environment, the importance of experience, and the interaction with callers. All the telenurses remarked on the stress of work, which was often related to situations they had no control over: It doesn't matter how much statistics we have about the number of callers.... they [callers] still have to wait

30 minutes. We have no control over when people get sick. It's getting ridiculous.... that we have to answer 90% of all calls within three minutes. (Nurse A)

“It's getting ridiculous.... that we have to answer 90% of all calls within three minutes.” They described how, during flu epidemics, work could be very intense, and hearing the same symptoms over and over again increased the risk for missing important signals from callers. Always being aware of the number of calls waiting, and always feeling the pressure of organizational goals, could result in premature closure of calls. One telenurse described the stress that could be related to the physical work environment: Many of us need peace and quiet in order to work... and I just can't work in a room with four people around me. Sometimes I'm forced to do so, but after three hours I get a headache... there is too much going on.... it's so easy to lose focus. (Nurse C)

Night shifts were often less well staffed—which meant long working hours for the telenurses—and little opportunity to rest. Consequently, it could be difficult to make decisions regarding callers’ needs. Many of the incidents leading to malpractice claims occurred during night shifts, as illustrated in the following quote: Telenurse: The worst time for me is between four and five in the morning. Interviewer: Do you believe that contributed to what happened? Telenurse: Absolutely. Working too many hours. During the days, the computer reminds me when to take a break.... we don't have that at night.... you end up sitting there...10 hours in a row. (Nurse A)

TABLE 1. Example: Coding and Categorizing Significant Statements Meaning unit But the tiredness, when it comes during periods of stomach flu…or influenza. When you say the same thing… the same thing… same thing over and over and over again so after the 10th call you wonder… have I said anything… or half of what I should say… or too much… but you hear yourself so much that you get tired of yourself. What can you do? (Nurse C)

Code

Subcategories

Category

Stress and monotony related to intensity of work during flu epidemics

Effect of work environment

Telenurses’ perspectives

Domain Potential factors contributing to incident that led to malpractice claim




39

TABLE 2. Domains, Categories, and Subcategories Domain

Category

Factors that may have contributed Telenurses’ perspectives to outcome of incident, which led to a malpractice claim Managers’ perspectives

Consequences of malpractice claims

Telenurses’ perspectives

Managers’ perspectives

Another telenurse believed that the incident that led to her involvement in a malpractice claim was partly because of her inexperience, not as a nurse but as a telenurse: It happened when I had just started working at 1177.... I had only worked a few months, and still felt unsure.... it takes time to learn the job. (Nurse B)

This quote also illustrates one of the biggest challenges of the telenursing task, dealing with uncertainty. The telenurses described how they readily consulted each other when assessing callers’ symptoms and made special efforts to help newly hired colleagues understand the importance of asking for help if in doubt. In many of the incidents leading to malpractice claims, the telenurses involved had not spoken directly with the patient. They realized, looking back, that they had completely relied on the caller’s description and interpretation of the patient’s situation, which proved to be misleading: No...no [I never spoke to the patient]. I spoke to her husband.... it seemed so natural.... he called because he was worried about her.... I didn't understand the situation.... maybe he couldn't explain.... and I didn't ask the right questions. (Nurse B)

Some malpractice claims were based on misunderstandings between telenurses and callers. Patients did not always fully understand instructions or advice or did not understand that the telenurses had expected the patient to make the final decision regarding advice given: We can't see the patient...so I think that people calling on behalf of children or old parents, who actually see the patients, should take the responsibility, no matter what we have said. (Nurse D)

Callers could misinterpret or deny certain symptoms or even fail to give the telenurse, intentionally or unintentionally, background information about their previous medical history. Many callers seemed to expect medical diagnoses and guarantees

Subcategory Effect of work environment Inexperience Interaction with callers Complexity of work task Inexperience Telenurses’ communication with callers Lessons learned Psychological consequences Need for support Learning from mistakes Changes in work environment Focus on in-service training for telenurses Focus on training in communication process for telenurses

and did not appear to understand that the telenursing service offers triage and advice. Managers Managers focused on the complexity of the telenursing task, the importance of experience, and telenurses’ communication with callers. They saw multitasking as one of the more specific challenges in telenursing (i.e., being able to work with both computer documentation and DST while gathering information from callers): A description of the required competencies was produced--there are so many---there is ethics and technology and medicine, and communication. There are so many---so when a nurse starts here she has so much to learn--and unfortunately, it is often the technology that takes over in the beginning---‘‘If I open the decision support system and I shut down there and then I have to get into another program.’’ The technology--it is the biggest part when a nurse is new--then when she is able to handle that---she starts to think about medicine---‘‘OK--what do I do about this sickness and that sickness’’---and then she starts to think---‘‘I don't know so much about pediatricsor---I can't do that.’’ Then come the communication skills---way down on the list. (Manager C)

They realized that, for many telenurses, this required time to adjust to. They were also aware that experience among telenurses varied and, consequently, closely monitored individual telenurses, giving extra support if necessary. Almost all the managers emphasized how telenurses needed to understand the importance of their communication with callers: There are so many pitfalls.... the patient makes his own diagnosis...that he has stomach flu and we go straight to advice on stomach flu. We forget that we should ask about this and that...to make sure the patient doesn't have appendicitis...or something else. Maybe the patient has been to a doctor...the same day or day before... and the doctor made a diagnosis...which we accept...


40


instead of asking...what is the reason for your call today... has anything changed. (Manager A)

Consequences of the Malpractice Claims Telenurses Lessons learned by telenurses were based on the incidents that had led to the malpractice claim. A lesson learned was the importance of understanding one’s physical and mental limits when working night shifts. Most of the lessons learned led to changes in the way the telenurses communicated with callers. These changes included always trying to speak directly to the patient, using open-ended questions to collect as much information as possible, not jumping to conclusions, and being as clear as possible when ending calls—to ensure that the callers had understood given advice.

A lesson learned was the importance of understanding one's physical and mental limits when working night shifts. Some (although not all) telenurses had not considered possible risks involved in giving advice over the telephone and were taken by surprise when informed about the malpractice claim. However, according to all the telenurses, a difficult lesson learned was the fact that they were not infallible: I feel I don't want to end up in this situation again. But I am very aware that it can happen again. The risk is great...since I can't see the caller...can't feel the caller.... so there is a big chance it can happen again...to me... or to a colleague. (Nurse E)

Involvement in malpractice claims had many psychological consequences. The telenurses’ descriptions of their reactions revealed they were not open when it came to talking about difficult calls or their involvement in malpractice claims: The climate could be a bit more open...but I believe most of us feel we are ‘‘bad nurses’’ if it happens...because I felt that way. If somebody asks me directly, I don't hide what happened, but I don't go talking about it, that's for sure. (Nurse F)

At the same time, they were very much affected by their involvement in a malpractice claim. Even if feelings of shock, failure, or shame abated with time, they lost confidence in themselves. The period during the investigation was very trying and something they did not want to experience again. The malpractice claim was never really forgotten. The immediate support and understanding from the manager were appreciated and very important. However, the need


for continuing support and follow-up differed. Some telenurses appreciated the psychological counseling offered by the managers, whereas others felt they had no need of support and refused. Involvement in a malpractice claim could be very traumatic, depending on the seriousness of the incident and outcome for the patient. Although not at fault, some telenurses were devastated and felt the need for extra support—even rehabilitation—to be able to return to work again. Managers The managers saw it as their responsibility to learn from each and every malpractice claim. They made efforts to create a more open climate regarding mistakes and safety and tried to instill in the telenurses an understanding that nobody is infallible: I want to play down...and learn instead. When hiring new personnel...I tell them that you are going to make mistakes...and you will realize you made the mistakes...because how can you do the right thing if you are not aware of what you do wrong? (Manager A)

Some managers enforced changes in the work environment to protect telenurses against overworking. Work schedules were changed so as to cover an increased number of calls during holidays or influenza epidemics. Nurses were encouraged to take regular breaks to avoid fatigue. Telenursing administration heads were informed of areas that lacked clarity in the DST and had led to misunderstandings between telenurses and callers. Telenurses were consequently and regularly informed of any changes in the DST. More focus was placed on in-service training of the telenurses. Lectures on different medical conditions were given regularly at staff meetings by the medically responsible doctor or medical specialists and appeared to be appreciated by the telenurses. Strange and suspicious symptoms to watch out for, difficult callers, recent incidents, and near misses were shared and discussed. Introductory courses for newly hired telenurses became more comprehensive and included a mentor system at some call centers. As early as possible, managers tried to identify any problems telenurses appeared to have in their communication with callers that could lead to errors. They gave all telenurses a chance to listen to and learn from their own calls to try to avoid common communication pitfalls. They also encouraged telenurses to always follow the same comprehensive process protocol in all calls with patients: We really work on the communication process...listen to calls...discuss the pitfalls...how easy it is to end up there.... what to think about. They listen to their colleagues.... we have an open climate.... they ask each other...sound each other out. (Manager B)

DISCUSSION Previous research has identified stress related to organizational demands and flu epidemics, communication pitfalls (most notably



not speaking directly to the patient), difficulties in the interaction between telenurses and callers, and uncertainty as possible safety risks in telenursing (Farquharson et al., 2012; Röing, Rosenqvist, & Holmström, 2013; Wahlberg, Cedersund, & Wredling, 2003). These factors have now been identified in actual incidents, which led to malpractice claims by telenurses in this study. An interesting finding involving the communication between telenurses and callers revealed dilemmas of telenursing, which can lead to errors. Many of the telenurses in this study expected the callers to make the final decision regarding given advice. Situations (which led to malpractice claims) were described where callers—advised to contact emergency services if they felt their conditions had worsened—had not heeded this advice. Although many patients nowadays appreciate the opportunity to be involved in decisions regarding their health and treatment (Charles, Gafni, & Whelan, 1997), it is possible that, in situations of high urgency, some callers expect and want to be told what to do by the telenurse and not be provided with options to choose from (Leprohon & Patel, 1995). Furthermore, patients’ interpretations of their symptoms and how they perceive and respond to illness vary and can depend on age, gender, education, cultural or ethnic background, and previous medical history (Bates, Edwards, & Anderson, 1993; Turner & Nido, 1988). Hence, clear communication and a thorough investigation of callers’ fears and expectations are needed in every call (Pendleton, 1984). This is something Swedish telenurses are specifically encouraged to do, as it is in line with the dialogue process they have been trained to follow (Runius, 2008).

Many of the telenurses in this study expected the callers to make the final decision regarding given advice. Shiftwork and multitasking (e.g., communicating with callers while simultaneously working with the computer documentation software and DST, factors embedded in the system) may have contributed to malpractice claims. Many of the incidents described by the telenurses had occurred in the very early hours of the morning, at the end of their shifts. It is well known how certain shifts can affect the well-being of all shift workers, irrespective of occupation and, thus, affect safety in the work environment (Folkard & Tucker, 2003). Although there are individual differences, shift workers become all the more vulnerable to involuntary drowsiness as a night shift wears on and, consequently, have difficulties maintaining a high state of wakefulness (Arendt, 2010). Multitasking is also a very necessary aspect of telenursing and requires a high level of concentration. Preoccupation with documentation and DST can interfere with a telenurse’s thought processes (Rutenberg & Greenberg, 2012). Other negative effects include stress, focusing on one task


41

at the expense of another, and cognitive overload (Dekker, 2011, p. 70). Thus, the demands of multitasking, together with fatigue and stress, could have increased the risk for not picking up important details or signals from callers. As for the safety culture in telenursing, descriptions of the consequences of the malpractice claims at the call centers suggest a bureaucratic safety culture. No changes were made regarding overarching goals and priorities. Changes at the blunt end included improvements in work environment for the telenurses and efforts to create a more open climate regarding errors and safety. Other changes focused on changing the individual behavior of the telenurses, education, and in-service training in communication. This is congruent with a recent study on malpractice claims in Swedish telenursing, which revealed the most common measures taken to be discussions within work groups and education of staff (Ernesäter et al., 2012). Telenurses —reluctant to talk to colleagues and others about their involvement in malpractice claims—were offered support by their managers who were often empathetic and who also kept them informed during the investigation process, all in private. In this manner, safety management appeared to be compartmentalized. Focus on individual behavior of the telenurses is understandable to a certain extent, as the outcome of a call is based entirely on the interaction between a telenurse and caller, something telenurses are acutely aware of. This may explain why some telenurses, although not always at fault, blamed themselves. The feelings of devastation felt by some telenurses also reveal how difficult it may be to overcome unwritten norms within the medical and nursing community, that viewing error as “failure of character” and “mistakes as unacceptable” (Leape, 1994). Strategies for safer healthcare systems should include designing the system to prevent errors, designing procedures to make errors visible when they do occur, and designing procedures for reversing or halting the harm caused to the patient (Nolan, 2000). If, as the findings of this study suggest, errors in telenursing can arise by factors that seem to be inherent in the system, it is all the more important for the organization to work toward designing a system and work environment that supports the telenurses as theyworkwith the telenursing process in identifying and meeting individual needs of callers (Rutenberg & Greenberg, 2012). Research efforts should begin with investigation of attitudes to safety and behavior before and after training interventions (Sexton, Thomas, & Helmreich, 2000).

Limitations Four widely used criteria in the discussion of trustworthiness of qualitative studies are credibility, dependability, confirmability, and transferability (Guba & Lincoln, 1989). In this study, in striving for credibility, the procedures for selection of relevant study participants, data collection, and analysis were presented as thoroughly as possible. Citations were used to show that the findings were grounded in the interview texts to assure


42


confirmability. To uphold the criterion of dependability, the research process was described in detail to make it possible for the reader to agree with and understand the logic of the findings. The Swedish context, and the fact that it is based on a small sample of participants, is a threat to transferability or the extent to which the findings can be transferred to other contexts and settings. However, most (although not all) of the telenurses and managers worked in different call centers, which had different sizes and which were distributed over the country. All participants wholeheartedly shared their experiences of involvement in malpractice claims, resulting in rich data on the perspectives of both managers and telenurses. Another strength may be the different backgrounds of the authors, as both the etic perspectives of the first author (as an observer to telenursing) and the emic perspectives of the second author (based on her experience of telenursing) were used in the analysis.

Conclusions To the best of our knowledge, this is the first study investigating experiences of actual malpractice claims in telenursing—a rapidly growing service in many Western countries. Some changes in the safety culture appeared to be underway at the individual call center sites of the telenurses and managers who had participated in this study. However, the reactions of the telenurses to their involvement in malpractice claims, and the fact that changes in overarching organizational priorities and goals were not mentioned, suggest the need for changes in both organizational and professional attitudes toward safety and risk for error. Accepted for publication August 26, 2014. The authors would like to give special thanks to the participating telenurses and managers. Grants were received from AFA insurance. The authors declare no conflicts of interest. Corresponding author: Marta Ro¨ing, PhD, Department of Public Health and Caring Sciences, Health Services Research, University of Uppsala, Box 564, SE-751 22 Uppsala, Sweden (e-mail: [email protected]).

REFERENCES 1177 Vårdguiden. (2014). 1177 Vårdguiden Sjukvårdsrådgivningen (Swedish Healthcare Direct 1177). Retrieved from http://www.1177 .se/Uppsala-lan/Om-1177/Om-1177/ American Academy of Ambulatory Care Nursing. (2007). Telehealth nursing practice scope and standards of practice (4th ed.). Pitman, NJ: Author. Arendt, J. (2010). Shift work: Coping with the biological clock. Occupational Medicine, 60, 10–20. doi:10.1093/occmed/kqp162 Armitage, G. (2009). Human error theory: Relevance to nurse management. Journal of Nursing Management, 17, 193–202. doi:10.1111/ j.1365-2834.2009.00970.x Bates, M. S., Edwards, W. T., & Anderson, K. O. (1993). Ethnocultural influences on variation in chronic pain perception. Pain, 52, 101–112. doi.10.1016/0304-3959(93)90120-E Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: What does it mean? (or it takes at least two


to tango). Social Science &Medicine, 44, 681–692. doi:10.1016/S02779536(96)00221-3 Dekker, S. (2011). Patient safety: A human factors approach. Boca Raton, FL: Taylor & Francis. Ernesäter, A. (2012). National telephone advice nursing in Sweden: Patient safety and communication. Uppsala, Sweden: Uppsala University. Retrieved from http://uu.diva-portal.org/smash/get/diva2: 532709/FULLTEXT01.pdf Ernesäter, A., Winblad, U., Engström, M., & Holmström, I. K. (2012). Malpractice claims regarding calls to Swedish telephone advice nursing: What went wrong and why? Journal of Telemedicine and Telecare, 18, 379–383. doi:10.1258/jtt.2012.120416 Farquharson, B., Allan, J., Johnston, D., Johnston, M., Choudhary, C., & Jones, M. (2012). Stress amongst nurses working in a healthcare telephone-advice service: Relationship with job satisfaction, intention to leave, sickness absence, and performance. Journal of Advanced Nursing, 68, 1624–1635. doi:10.1111/j.1365-2648.2012.06006.x Folkard, S., & Tucker, P. (2003). Shift work, safety and productivity. Occupational Medicine, 53, 95–101. doi:10.1093/occmed/kqg047 Guba, E. G., & Lincoln, Y. S. (1989). Fourth generation evaluation. Newbury Park, CA: Sage. Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277–1288. doi:10.1177/1049732305276687 Johansson, H. (2010). The Swedish system for compensation of patient injuries. Upsala Journal of Medical Sciences, 115, 88–90. doi:10.3109/ 03009730903350749 Kaminsky, E. (2013). Telephone nursing: Stakeholder views and understandings from a paediatric and a gender perspective. Uppsala, Sweden: University of Uppsala Retrieved from http://uu.diva-portal .org/smash/get/diva2:646194/FULLTEXT02.pdf Leape, L. L. (1994). Error in medicine. Journal of the American Medical Association, 272, 1851–1857. doi:10.1001/jama.1994.03520230061039 Leppänen, V. (2008). Historical background. In I. Holmström (Ed.), Telefonrådgivning inom hälso-och sjukvård [Telephone advice within healthcare] (pp. 19–36). Lund, Sweden: Studentlitteratur. Leprohon, J., & Patel, V. L. (1995). Decision-making strategies for telephone triage in emergency medical services. Medical Decision Making, 15, 240–253. doi:10.1177/0272989X9501500307 National Board of Health and Welfare. (2013). Tillsynsrapport 2013 Hälso-och sjukvård och socialtjänst [Inspection of healthcare and social services 2013]. Stockholm, Sweden. Retrieved from http:// www.ivo.se/publiceratmaterial/rapporter/Documents/Tillsynsrapport2013.pdf Nolan, T. W. (2000). System changes to improve patient safety. British Medical Journal, 320, 771–773. doi:10.1136/bmj.320.7237.771 Norris, B. (2009). Human factors and safe patient care. Journal of Nursing Management, 17, 203–211. doi:10.1111/j.1365-2834.2009 .00975.x Odegård, S. (1999). From punishment to prevention? Medical errors reported in Sweden in 1989 and 1993. Safety Science Monitor, 3, 1–10. Parker, D. (2009). Managing risk in healthcare: Understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF). Journal of NursingManagement, 17, 218–222. doi:10 .1111/j.1365-2834.2009.00993.x Pendleton, D. (1984). The consultation: An approach to learning and teaching. Oxford, UK: Oxford University Press. Reason, J. (2000). Human error: Models and management. British Medical Journal, 320, 768–770. doi:10.1136/bmj.320.7237.768 Reason, J. (2005). Safety in the operating theatre—Part 2: Human error and organisational failure. Quality and Safety in Health Care, 14, 56–60.



Röing, M., Rosenqvist, U., & Holmström, I. K. (2013). Threats to patient safety in telenursing as revealed in Swedish telenurses’ reflections on their dialogues. Scandinavian Journal of Caring Sciences, 27, 969–976. doi:10.1111/scs.12016 Runius, L. (2008). Giving advice in health care—The good dialogue. In I. Holmström (Ed.), Telefonrådgivning inom hälso-och sjukvård [Telephone advice within healthcare] (pp. 63–77). Lund, Sweden: Studentlitteratur. Rutenberg, C. D., & Greenberg, M. E. (2012). The art and science of telephone triage: How to practice nursing over the phone. Pitman, NJ: Jannetti Publications. Sexton, J. B., Thomas, E. J., & Helmreich, R. L. (2000). Error, stress, and teamwork in medicine and aviation: Cross sectional surveys. British Medical Journal, 320, 745–749. doi:10.1136/bmj.320 .7237.745 Smith, C., Valsecchi, R., Andersson, M., & Sederblad, P. (2012). Telenursing: the English and Swedish Cases. School of Management, Royal Holloway University of London. Working Paper Series SoMWP1203. Retrieved from http://digirep.rhul.ac.uk/file/1d471647-50a0606a-669c-bc6b8838e85c/1/Smith%2C%20C%20working%20paper %20Telenursing%20the%20English%20and%20Swedish%20Cases.pdf Socialstyrelsens författningssamling. (2005). Socialstyrelsens föreskrifter och allmänna råd om anmälningsskyldighet enligt Lex Maria [The National Board of Health and Welfare’s regulations and guidelines


43

regarding compulsory reporting according to Lex Maria]. Kungälv, Sweden: Grafikerna Livrena i Kungälv AB. Retrieved from http:// www.socialstyrelsen.se/sosfs/2005-28/ Studdert, D. M., & Brennan, T. A. (2001). No-fault compensation for medical injuries: The prospect for error prevention. Journal of the American Medical Association, 286, 217–223. doi:10.1001/jama .286.2.217 Sveriges Riksdag. (2010). Patient Safety Act (in Swedish, Patients äkerhetslag [2010:659]). Retrieved from http://www.riksdagen.se/ sv/DokumentLagar/Lagar/Svenskforfattningssamling/Patientsakerhetslag2010659_sfs-2010-659/?bet=2010:659 Swedin, B. (2003). Vårdråd direkt–sjukvårdsrådgivningar i samverkan [Healthcare advice direct—Healthcare call centers in cooperation]. Stockholm, Sweden: Landstingsförbundet. Turner, B. J., & Nido, R. M. (1988). Urgency in seeking medical care for specific symptoms: Perceptions of physicians and patients. Journal of General Internal Medicine, 3, 245–249. doi:10.1007/BF02596339 Wahlberg, A. C., Cedersund, E., & Wredling, R. (2003). Telephone nurses’ experience of problems with telephone advice in Sweden. Journal of Clinical Nursing, 12, 37–45. doi:10.1046/j.1365-2702 .2003.00702.x Westrum, R. (2004). A typology of organisational cultures. Quality and Safety in Health Care, 13, ii22–ii27. doi:10.1136/qhc.13.suppl_2.ii22

Call for Papers: Biology Reviews for Nursing Research

Nursing Research invites integrative reviews of current advances in basic biological sciences and translational research relevant to emerging areas of nursing science. Areas of interest include but are not limited to topics in: genetics, genomics, and epigenetics; systems biology/integrative physiology; neuroscience and imaging; computational biology; microbiology and the human microbiome; nanoscience; physiology in situ and mobile health devices. Biology Reviews for Nursing Research will provide up-to-date information about advances in these thematic areas to the global community of nurse scientists, with the aim of infusing new biological and “omics” knowledge into nursing research. Reviews should summarize and critically evaluate the current state of knowledge. Implications for nursing research in relevant areas should be addressed, especially with respect to the priority research addressing prevention and treatment of disease and disability; symptoms and symptom management of acute and chronic illnesses; interventions for compassionate end-of-life and palliative care; infectious disease and global health; and integration of biological and behavioral perspectives on health over the lifespan across priority areas. Papers accepted for Biology Reviews will be published as features in regular issues of Nursing Research. Queries are encouraged and should be sent to Dr. Susan Henly, Editor ([email protected]). Information for Authors is available at: http://journals.lww.com/nursingresearchonline/_layouts/1033/oaks.journals/ informationforauthors.aspx. Nursing Research is indexed or abstracted in Medline, CINAHL, JCR Science Citation Index, PsychInfo and Thomson Reuters Web of ScienceSM.


Lessons learned from reviewing breast imaging malpractice cases.

Towards personalized smart wheelchairs: Lessons learned from discovery interviews.

Trends in obstetric malpractice claims.

Psychological Model for Presymptomatic Test Interviews: Lessons Learned from Huntington Disease.

The lawyers' role in medical malpractice claims.

Surgical malpractice claims in the United States.

Lessons learned from hospice care.

Emotional distress claims in medical malpractice cases.

Lessons learned from comparative and evolutionary physiology.

Counting the cost of negligence in neurosurgery: Lessons to be learned from 10 years of claims in the NHS.

Patient-centered care in diagnostic radiology: lessons learned from patient interviews prior to musculoskeletal magnetic resonance imaging.

Lessons learned using Web conference technology for online focus group interviews.

Anesthesia- and opioids-related malpractice claims following tonsillectomy in USA: LexisNexis claims database 1984-2012.

Lessons learned from genetic testing for channelopathies.

Maternal microchimerism: lessons learned from murine models.

Lessons Learned.

Lessons learned from the brute beast.

Lessons learned from a SIRT2-selective inhibitor.

Lessons learned from litigation: maintaining professional boundaries.

Transradial access: lessons learned from cardiology.

From lessons learned to emerging practices.

Lessons learned from hospital Ebola preparation.

ARDS: lessons learned from the heart.

Lessons learned from national surgical audits.