Telephone communication between practice nurses and older patients with long term conditions – a systematic review

Introduction

Long term conditions (LTCs) are the most significant health problem faced by older people internationally. ¹ Significantly, multimorbidity is increasing in the older population. ² Ways of overcoming barriers to effective health care, including those relating to access and effective communication, are urgently required. ³ A particular identified priority is to enable primary health care to become more age friendly. ⁴

In this paper we define telephone communication as any conversations between the practice nurse and the patient. In certain countries, such as New Zealand, Australia and the United Kingdom, the practice nurse is traditionally employed by a General Practitioner (GP) and nurses provide care to their enrolled population from the general practice or surgery site. We used the term telephone communication in a broad manner, so it includes types of communication such as telephone triage and telephone consultations. Telephone communication is already recognised as a means of delivering health care, improving access to care, and a means by which patients can obtain health information. ⁵ Information and advice which is easily accessible is especially important for those with LTCs.^6,7 Furthermore, having the ability to consult a health professional over the phone means patients do not need to be absent from work, they save on travel costs and do not need to arrange child care. ⁶

Telephone consultation may also help reduce the growing costs associated with providing health care to the aging population, many of them living at home and needing extra support to maintain their independence. With a greater number of older people with LTCs staying at home, and many living alone, there is a growing need for affordable health care for this population. ⁸ Older people are more likely to have transportation problems ⁹ and more mobility issues, ¹⁰ making trips to health care professionals more difficult. In this context, telephone communication is a flexible low cost option to provide patient care. ¹¹

Specific types of telephone support have been developed and tested, such as telephone case management for patients with heart failure. ¹² Similarly, Hunkeler et al. ¹³ found that a nurse telehealth support system was more effective than antidepressants in the treatment of patients with mild to moderate depression, with 58% of participants in the phone call group recovered compared with 37% in the control group. Other studies have used non health professionals, such as lay health workers or peer support workers, to provide telephone based interventions. ¹⁴

Research has identified that primary health care nurses already use telephone communication with patients, ¹⁵ although this role is often not made explicit. ¹⁶ GPs have also identified that they see telephone communication as integral to the routine work of primary health care nurses. ¹⁷ Telephone consultations with nurses has been found to reduce the doctors' workload and benefit patients who wish to be seen on the same day. ¹⁸

However, questions have been raised about the quality and safety of telephone consultations, including timeliness to determine urgency levels particularly when a triage system is used,^5,19 patients' ability to communicate about their symptoms over the telephone and the type and usefulness of information and advice provided to patients. ²⁰ There is some evidence that further training in telephone communication is required for nurses,^5,13,20 suggesting that telephone communication skills can be improved to meet patients' needs.

It was with this context in mind that we sought to synthesise the evidence in this area by conducting a systematic literature review to identify the range and scope of telephone use between nurses working in primary health care and older people.

Aims

To examine the extent to which practice nurse–patient telephone communication has been used previously with older people.

Methods

A literature search strategy was devised and assistance obtained from a specialist librarian. The following databases were searched: Medline, CINAHL, Web of Science, and EMBASE. The reference lists of included papers were also searched. Searches were conducted between July 2015 and August 2015.

Combinations of the following search terms were used:

Primary Health Care, Nurse, Practice Nurse, Primary Nurse, Primary Care Nurse;

Study inclusion criteria were as follows:

Original research articles;

Studies containing participants who are practice nurses in primary care settings.

We excluded review articles and studies including residents of long term care facilities. This decision was made because residents of care facilities in New Zealand do not generally go to general practices to receive primary medical care; instead they receive doctor or specialist nurse visits in the facility. Furthermore residential care facilities have registered nurses on staff, so residents are not going to be communicating with medical practitioners via the telephone.

Results

The search results are summarised in the PRISMA flowchart ²³ (Figure 1). Overall, five studies met the inclusion criteria (see Table 1). Of these, three studies used quantitative methodologies, one used qualitative and one used a mixed methods approach. Two of the studies were conducted in the United States (USA), two were conducted in Australia (part of the same research) and one was conducted in Germany. OPEN IN VIEWER

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Table 1.

Summary of papers.

Author	Purpose	Study design	Setting and sample	Summary of results (relating to telephone communication)	Quality assessment
Mons et al. 24	To investigate whether a patient-centred intervention comprising monthly supportive telephone-based counselling sessions by practice nurses in a general practice setting improves diabetes-related medical and psycho-social outcomes above usual care in diabetes patients	Quantitative	Country: Germany Setting: general practices Sample size: 204 Age range (years): mean IV group = 68, control = 67	- No significant difference in HbA1c between IV and control – both decreased - However, there were significant differences for IV group in HRQoL and transiently for blood pressure and depression	26/27
Wakefield et al. 28	To look at the differences in communication profiles between telephone and videophone interactions and whether these profiles change after time	Quantitative	Country: USA Setting: data drawn from a larger RCT evaluating telehealth home care for older veterans with heart failure Sample size: 28 Age range (years): mean age = 70	- There were no significant differences in patient satisfaction between telephone and videophone - No significant difference in communication profiles over time	25/27 - Not clear about confidentiality - Mainly Caucasian sample
Walters et al. 26	To investigate health behaviour changes adopted by people with moderate or severe COPD during a RCT of telephone delivered health mentoring to support self-management in primary care	Qualitative	Country: Australia Setting: patients from 31 general practices Sample size: 44 Age range (years): mean age = 65.2	- Telephone delivery was highly acceptable and enabled good rapport – the programme helped improve the targeted health behaviours – physical activity and smoking cessation	24/27 - Methods section a bit confusing - Not much written about ethics and bias
Walters et al. 27	To look at the barriers and enablers to practice nurses providing health mentoring to patients with COPD	Mixed methods	Country: Australia Setting: nurses from general practices interested in health mentoring Sample size: 5 Age range (years): 36–60	- The nurses did not express reservations on the effectiveness of telephone support, but found that the time for scheduled time calls was frequently supplanted or interrupted by other tasks. Phone calls were given a lower priority than face-to-face consultations	25/27 - Aims not very clear
Weinberger et al. 25	To examine the impact of a nurse-coordinated intervention delivered by phone to patients with NIDDM between office visits to a primary care physician	Quantitative	Country: USA Setting: general medical clinic of the Durham Dept of Veterans Affairs Medical Center Sample size: 275 Age range (years): mean age = 64	- Glycaemic control was better in IV patients but there was no significant difference in HRQoL or diabetes-related symptoms.	25/27 - Participants from only one centre

IV: intervention; HRQoL: health-related quality of life; RCT: randomised controlled trial; COPD: chronic obstructive pulmonary disease; NIDDM: non-insulin dependent diabetes mellitus

Discussion

This review identified a wide range of telephone interventions that had a specific focus on supporting targeted self-management behaviours for people with LTCs. Whilst all the interventions had a telephone component, they were largely directed by nurses following specific protocols. Whilst all the studies had older people as participants, the interventions were not targeted specifically at older people and their individual needs. This is an important finding as older people have a higher risk of multimorbidity and targeting specific LTCs is inappropriate. ²⁹ Multimorbidity is more complex in the older person and can mean a significant increase in the need for consultation with primary care. ³⁰ However, this may have cost implications for the older person.

Apart from nurses developing a ‘rapport’ with the patient it was unclear whether any aspect of telephone communication contributed most to the success of the programme. Few barriers to telephone communication were identified. Although in one study while the nurses did not express reservations on the effectiveness of telephone support, they found that the time for scheduled time calls was frequently supplanted or interrupted by other tasks. Phone calls were given a lower priority than face-to-face consultations. ²⁷

Conclusion

The studies reviewed focused on specific LTCs or comorbidity rather than the increasing challenge for the older person of living with multimorbidity. Studies that build on integrating current nurse led telephone services in primary care rather than developing separate services need further development and evaluation. Importantly, this review highlights the lack of research examining how the older person views telephone communication and management, in particular primary health care nurse–patient telephone communication and how the older person can be involved in improving nurse–patient telephone services that meet their needs.

More research needs to be conducted in the area of telephone communication for older people with LTCs, as this type of health care delivery may be essential in coping with the growing population of older people with multimorbidity. The more accessible health care communication via telephone may provide the older person with the support they need to manage their health conditions, but also remain living independently in their own homes.