- Email: [email protected]
Counseling parents of children with acute illness: A task for nurses in an emergency clinic
INTERNATIONAL PEDIATRIC N U R S I N G Column Editor: Bonnie Holaday, DNS, RN, FAAN
Counseling Parents of Children With Acute Illness: A Task For Nurses in an Emergency Clinic Venke SCrlie, RNT, MSc Hasse Melbye, MD, PhD Astrid Norberg, RN, PhD 'URSING CARE is often described as focus-
N ing on the patient's daily life in relation to health status whereas doctoring (medicine) is de-
scribed as focusing on pathology (Camevali, 1992, pp. 22-44). However, nurses do not only work with typical nursing care activities but are also engaged in performing delegated medical tasks. Telephone counseling is such a task (Bhopal & Bhopal, 1988). Telephone counseling is an important and extensive part of primary health care (Bhopal & Bhopal, 1988, Marklund & Bengtsson, 1988). Three major children's hospitals in the United States have provided such a service whereby nurses have given free telephone counseling to parents of sick children. The telephone services reduced the number of physicians' consultations, and parents expressed positive feelings about not having to visit the hospital. The parents also derived satisfaction from being able to treat their sick children (Stamp & Kreusser, 1990). Nurses in Sweden have extensive experience offering telephone services in departments of primary health care, and studies have shown a great satisfaction with the service (Malmberg, 1981; Marklund et al., 1990). In the very few studies describing the work in emergency clinics in Norway (Borchgrevink & Bruusgaard, 1981; Rytter, 1989; Otterstad, 1991), telephone counseling by nurses has been mentioned, but has neither been described nor evaluated. The aim of the study was to describe nurses' telephone counseling of parents of sick children and the parents' satisfaction with the service.
MATERIAL AND METHOD The study was conducted at the Municipal Emergency Clinic in Tromsr which serves a population of about 50,000 people distributed Journal of Pediatric Nursing, Vol 11, No 5 (October), 1996
over a radius of 160 kilometers. The clinic is the only primary care institution in Troms0 that offers treatment of acute cases every day between the hours of 4:00 PM and 8:00 AM. Each day the clinic is staffed by two physicians and two registered nurses. One doctor is responsible for the care in the clinic while the other visits patients in their homes. All the 13 nurses in the emergency clinic were women aged between 34 and 60 years who had worked in the area for 3 to 21 years (mean, 15). The nurses are the first to have contact with the patients when they call on the telephone. They receive information and assess the urgency of the help needed. They give advice and decide together with the patients and their families whether or not a consultation with a doctor is necessary.
Registrations All telephone counseling sessions by nurses of parents with sick children (younger than 16 years old) were registered for a period of 1 week in November 1991 and 1 week in February 1992. All 13 nurses performed the registration while doing their telephone counseling. A registration form previously used in a similar study in the United States (Broome, 1986) was translated into Norwegian. Reasons for the consultation and other symptoms presented were noted as From the Depanmem of Nursing Science, and the Institute of Community Medicine, Universityof Tromsr Norway, and the Department of Advanced Nursing, Umed University, Sweden. Address reprintrequests to VeniceSCrlie, RNT, MSc, Department of Nursing Science, MH, Breivika, 9037 Tromsr Norway. Copyright 9 1996 by W.B. Saunders Company 0882-5963/96/1105-001353.00/0 337
338
SORLIE, MELBYE, AND NORBERG
RESULTS
key words, as well as the advice given. The parents' descriptions of the problems were afterwards classified in accordance with the International Classification of Primary Care system (ICPC). The advice given was classified as: observation, medication, nursing care, and advice about eating and drinking. The outcome of the consultation was assigned to one of the following three categories: (1) home visit by doctor, (2) visit to the emergency ward immediately or later the same day, and (3) advice to observe the child at home. The data were analysed using the Statgraphics software program (Bitstream, Inc., Cambridge, MA).
A total of 152 telephone consultations were registered. Of those who called, 113 (74%) were mothers, 35 (23%) fathers, two were grandmothers, one was an uncle, and one an employee at an institution. In this article they will all be labeled 'parents'. Half of the children were younger than 4 years of age (Figure 1) and 53% were boys. All in all, 37 symptoms were registered. Fever was the symptom most frequently presented. In 78 eases, (51%) fever was the first symptom that the parents mentioned. The 10 most frequent symptoms reported by the parents are shown in Table 1. As a result of the consultation, 18 children (12%) were visited by a doctor. Fifty-six parents (37%) were advised to take the child to the emergency clinic the same day, which they did. In 78 cases (51%), the parents were advised to observe their child at home. Additional advice was given to all parents and is shown in Table 2. In 18 of the 78 cases in which parents were advised to observe their child at home, the parents contacted the emergency clinic again during the next week, and medical treatment was prescribed for 10 of the 18 children (Table 3). In 9 cases antibiotics were prescribed: of these, 7 children were diagnosed as having otitis media, one with tonsillitis, and one with acute bronchitis. After 1 week, 10 of the 18 patients had recovered completely, and 8 were better or much better. The mean duration of the telephone consultations was 4.1 minutes (range, 1 to 10 minutes), compared with 4.3 minutes when the child was
Interviews
One week after the consultation, the parents who were advised to observe their child at home were telephoned and asked about the course of their child's illness. Parents who had made a subsequent contact with the emergency clinic or primary health care in the interim period were asked only about the child's recovery. Outcomes of later consultations were registered from medical records. The parents who neither called again nor visited the emergency clinic within 1 week were interviewed by the first author, who used a structured interview format. All questions could be answered with yes or no, but further spontaneous explanations were invited. Consensual validation was obtained by repeating each question and answer. The yes/no answers were counted. The spontaneous commentaries were listed and classified. The study was approved by the Regional Committee of Medical Research Ethics, Troms0. 30
25
20
No. of children
15
10
0 -~--m[~-1
Z
3
4
5
6
7
8
9
10
Years of life
11
12
13
14
15
16
Figure 1.
Distributionofyears
o f life in 152 children with acute
illness.
TELEPHONE COUNSELING PARENTS OF CHILDREN
339
Table 1. Frequency of Symptoms
Table 3. Time From Telephone Consultation to Treatment
Frequency of Symptom (%}
Frequency of Symptomas First Mentioned (%)
Delay Between TelephoneConsultation and Attendance~Visit
Attended the Clinic
Fever Cough Sore throat Other respiratory symptoms Fatigue/malaise Rash/itching Head ache
59 22 11 18 18 12 10
51 7 3 7 3 9 3
<1 day 1 day 2 days 4 days
5 7 1 3
Nausea~vomiting
11
1
Ear symptoms Accidents
11 7
7 7
178
100
To~I
1 1 ---
Medical Treatment Prescribed 3 4 1 2
NOTE. Registrations from the medical records at the emergency clinic of 18 sick children advised to be observed at home, but who later came to the ward or were visited by doctor. Delay between telephone consultation with the nurse and attendance/ visit, and prescription of medical treatment is listed.
NOTE. Frequency of the 10 most common symptoms of 152 children with acute illness described by parents calling an emergency ward, and the frequency with which each were the first symptom mentioned by the parents.
visited by a physician at home, 3.2 minutes when the child came to the emergency ward the same day, and 4.8 minutes when the parents were advised to await developments at home. Of the 60 parents who had neither called nor visited the emergency clinic after the telephone consultation, 58 were interviewed about the satisfaction with the service. Fifty-four of these had called the emergency clinic without having previously consulted anyone else. Sixteen parents (28%) had no one to ask for advice, and reported frequent contacts with the emergency ward for advice. All the parents reported having followed the advice given. All 58 children had improved or had fully recovered. The parents' answers to the yes/no questions about their satisfaction with the advice revealed that 54 parents (93%) thought that the advice was satisfactory. 52 parents (90%) thought that the advice had been helpful to the child. 44 parents (76%) had learned new things. The parents' spontaneous comments showed more specifically what they valued: Table 2. Advice Given to the Parents of the 152 Children
Special observation (such as loss of appetite, fever, level/type of pain) Medication (analgetics/antipyretics was recommended in 72) Nursing care (such as keeping the child in bed, oral care and reducing itching} Food and fluid (particularly fluid in connection with fever)
Visited by Doctor at Home
N
%
119
78
113
74
69
45
58
38
54 parents (93%) sought confirmation of care measures already taken. The advice had given them a feeling of security. 43 parents (74%) felt reassured when encouraged to call back or visit the emergency ward if the child's illness should change for the worse. 54 parents (93%) praised the nurses for their good performance. They emphasized the nurses' professional skills as well as their social skills. Most often they commented on both aspects in the same statement and did not specify one of these aspects to the detriment of the other.
DISCUSSION The high frequency of satisfied parents found in this study might have been lower if the parents who had made a subsequent consultation with the emergency clinic had been interviewed. It was thought that these parents would have difficulties in discriminating between the differing sources of advice and therefore would answer questions about the first telephone consultation inappropriately. The fact that all 18 parents took their child to the emergency clinic, and not to a general practitioner, indicates that most of them found the advice given to be reasonable. They had probably, as with the interviewed parents, been encouraged to take the child to the clinic if the child's condition deteriorated. The fact that most interviewed parents were satisfied with the advice given was probably connected with three factors that they mentioned. First, all children had recovered or improved. This could have been spontaneous and unrelated to the advice given or the care measures undertaken. Second, the encouragement by the nurses to contact them again if necessary made the parents feel secure. Third, almost all parents (93%) wanted confirmation of care measures that they had already under-
340
taken. In fact, 45 (75%) of the parents said that they often called the emergency ward. Many of these needed confirmation, as they felt uncertain about their own competence. The nurses could confirm the parents' understanding of the situation by expressing the same judgment, thereby promoting a sense of safety and security, strengthening the courage to act and share responsibility for the sick child's management. Parents need to have their actions confirmed by health care personnel and this is highlighted in an American study (Stamp & Kreusser, 1990). The telephone counseling of parents with sick children reduced the number of physicians' consultations, and parents expressed positive feelings about not having to visit the hospital. The parents also derived satisfaction from being able to treat their sick children. Therefore, it seems reasonable to assume that such confirmation and the easy access to the nurses was particularly important for the 16 parents (28%) who had no one else to ask for help. In an American study, Rauen (1985) described that most of Cope-line's callers either seek information or need to relieve stress rather than to resolve crises or emergencies. The philosophy of the parents' Cope-line is to support and help parents to "cope" with the situation. They frequently gain renewed inner strength and self-confidence. This correlates strongly with what the parents in this study said spontaneously. Fever was the most common symptom in this study. Children between 6 months and 3 years of age often contract infectious diseases with fever (Sherman, 1990; Jones, Maestri, & McCoy, 1993), and parents often make consultations concerning small children (Rutle, 1983). Therefore, it was not surprising that such an amount of the telephone counseling sessions concerned small children with fever. The mean duration of the telephone consultations (4.1 minutes) was similar to that found in other studies. In a Swedish investigation, the mean time, registered at six different health centers, ranged from 2.9 to 4.1 minutes (Marklund & Bengtsson, 1988). In a study from the United States, the consultation with nurses lasted for an average of 5 minutes (Moreland & Grier, 1986). The nurses at the emergency clinic meet a great number of sick children every day, and thus have great experience in assessing and prioritizing the severity of their illnesses. Their role has a focus similar to that of nurse practitio-
SORLIE, MELBYE,AND NORBERG
ners who focus on physical assessment, health promotion, and management of common pediatric problems (Keefe & Biester, 1993). They are also experienced in counseling parents of sick children over the telephone. In a British study, 41% of the out-of-hour calls were for children (McCarthy & Bollam, 1990). The nurses' experience may be important in explaining the parents' satisfaction. However, the small number of contacts in our study (152) does not permit an assessment of the risk of more or less serious errors, such as undertreatment of severe bacterial infection. The nurses are able to offer parents a home visit by a physician or can invite them to come to the emergency ward; telephone counseling is only one dimension of a broader health care service. Telephone counseling in isolation would probably not have been evaluated as positively by the parents. Telephone counseling by experienced nurses, as a complement to consultations with a doctor, may be of great value. Such counseling may be an economical and effective service that saves time and spares patients the difficulty of leaving home and undergoing medical examination, as pointed out in previous articles (Kjersgaard, Darre, & Rasmussen, 1985; Marklund et al., 1990; Stamp & Kreusser, 1990). It has also been pointed out that the costs of telephone counseling services are minimal, considering the large population that can be reached (Rauen, 1985; Elmer & Maloni, 1988). Our study showed that the nurses' telephone counseling mainly concerned medical matters such as special observation and medication. However, this does not automatically mean that the nurses acted only as less educated physicians. It seems reasonable to assume that their medical counseling was influenced by their nursing knowledge and experience. This question needs to be illuminated in future research.
CONCLUSION Most of the parents who were given telephone advice by a nurse on observing and taking care of their sick child did not need a second opinion, and they greatly appreciated the encouragement, the confirmation, and the information given to them by nurses.
ACKNOWLEDGMENT We are indebted to the nurses who participated in the study, and to the Tromsr Community for economic support.
TELEPHONE COUNSELING PARENTS OF CHILDREN
341
REFERENCES Bhopal, J.S., Bhopai, R.S. (1988). Outcome and duration of telephone consultations in a general practice. Journal of the Royal College of General Practitioners, 38, 566. Borchgrevink, C.F., Bruusgaard, D. (1981). Telefonkonsultasjon som alternativ til akuttsykebes~k. (Telephone consultation as an alternative to house calls from a physician). Tidsskrift for den Norske Leegeforening, 6, 398-401. Broome, M.E. (1986). Telephone protocols for pediatric assessment and advice. Journal of Emergency Nursing, 12, 142-146. Carnevali, D.L. (1992). Sykepleieplanlegging (Originally published 1976 under title Nursing Care Planning). Oslo: Ad Notam Gyldendal A/S. Elmer, E., Maloni, J.A. (1988). Parent support through telephone consultation. Maternal Child Nursing Journal, 17, 13-23. Jones, L.C., Maestri, B.O'B., McCoy, K. (1993). Why parents use the warm line. The ordinary worries of raising children of all ages prompt calls to a telephone counseling service. American Journal of Maternal Child Nursing, 18, 258-263. Keefe, M.R., Biester, D.J. (1993). Advanced practice in pediatric nursing. Journal of Pediatric Nursing, 8, 263-264. Kjersgaard, A.G., Darre, E., Rasmussen, O.V. (1985). Telefonr~dgivning fra en skadestue. (Telephone advice from an emergency ward). Ugeskift for L~eger, 147, 13631364. Malmberg, B.G. (1981). Telefonr~dgivning vid en v~trdcentral. V~rds6kandes attityder. (Telephone consultation at an emergency clinic. The patients' attitudes). Tumbaprojektet Report No 3, Huddinge Hospital, Stockholm, Sweden. Marklund, B., Bengtsson, C. (1988). Telefonr~dgiv-
ning--En omfattande verksamhet vid v~trdcentralerna. (Telephone advice--An extensive practice at the emergency clinics). L~kartidningen, 85, 4226-4228. Marklund, B., Bengtsson, C., Blomkvist, S., Furunes, B., G/icke-Herbst, Silfverhielm, B., et al. (1990). Evaluation of the telephone advisory activity at Swedish primary health care centres. Journal of Family Practice, 7, 184-189. McCarthy, M., Bollam, M. (1990). Telephone advice for out of hours calls in general practice. British Journal of General Practice, 40, 19-21. Moreland, H., Grier, M. (1986). Telephone consultation in the care of older adults. Geriatric Nursing, 7, 28-30. Otterstad, H.K. (1991). Legevakt i allmennlegetjenesteni Vestfold. (An emergency clinic in primary health care in Vestfold county). Tidssknft for den Norske Lzegeforening, 111, 1749-1751. Rauen, K. (1985). The telephone as stethoscope. American Journal of Maternal Child Nursing, I0, 122-124. Rutle, O. (1983). Pasienten fram i lyset--Analyse av legekontaktar i prim~erhelsetenesta. (The patient in focus-Analyses of consultations by physicians in primary health care). SIFF-rapport No 1/1983 Oslo: Statens institutt for folkehelse, gruppe for helsetjenesteforskning. Rytter, E.C. (1989). Legevakt i en storby. (An emergency clinic in a big city). Tidsskrift for den Norske Laegeforening, 109, 2539-2543. Sherman, W.G. (1990). What can I do when my child has a fever? Children's-- The Magazine of St. Louis Children's Hospital 1, 6. Stamp, B., & Kreusser, K.L. (1990). New answer line helps fill the parent information gap. Children's--The Magazine of St. Louis Children's Hospital, 1, 3-6.
Counseling Parents of Children With Acute Illness: A Task For Nurses in an Emergency Clinic Venke SCrlie, RNT, MSc Hasse Melbye, MD, PhD Astrid Norberg, RN, PhD 'URSING CARE is often described as focus-
N ing on the patient's daily life in relation to health status whereas doctoring (medicine) is de-
scribed as focusing on pathology (Camevali, 1992, pp. 22-44). However, nurses do not only work with typical nursing care activities but are also engaged in performing delegated medical tasks. Telephone counseling is such a task (Bhopal & Bhopal, 1988). Telephone counseling is an important and extensive part of primary health care (Bhopal & Bhopal, 1988, Marklund & Bengtsson, 1988). Three major children's hospitals in the United States have provided such a service whereby nurses have given free telephone counseling to parents of sick children. The telephone services reduced the number of physicians' consultations, and parents expressed positive feelings about not having to visit the hospital. The parents also derived satisfaction from being able to treat their sick children (Stamp & Kreusser, 1990). Nurses in Sweden have extensive experience offering telephone services in departments of primary health care, and studies have shown a great satisfaction with the service (Malmberg, 1981; Marklund et al., 1990). In the very few studies describing the work in emergency clinics in Norway (Borchgrevink & Bruusgaard, 1981; Rytter, 1989; Otterstad, 1991), telephone counseling by nurses has been mentioned, but has neither been described nor evaluated. The aim of the study was to describe nurses' telephone counseling of parents of sick children and the parents' satisfaction with the service.
MATERIAL AND METHOD The study was conducted at the Municipal Emergency Clinic in Tromsr which serves a population of about 50,000 people distributed Journal of Pediatric Nursing, Vol 11, No 5 (October), 1996
over a radius of 160 kilometers. The clinic is the only primary care institution in Troms0 that offers treatment of acute cases every day between the hours of 4:00 PM and 8:00 AM. Each day the clinic is staffed by two physicians and two registered nurses. One doctor is responsible for the care in the clinic while the other visits patients in their homes. All the 13 nurses in the emergency clinic were women aged between 34 and 60 years who had worked in the area for 3 to 21 years (mean, 15). The nurses are the first to have contact with the patients when they call on the telephone. They receive information and assess the urgency of the help needed. They give advice and decide together with the patients and their families whether or not a consultation with a doctor is necessary.
Registrations All telephone counseling sessions by nurses of parents with sick children (younger than 16 years old) were registered for a period of 1 week in November 1991 and 1 week in February 1992. All 13 nurses performed the registration while doing their telephone counseling. A registration form previously used in a similar study in the United States (Broome, 1986) was translated into Norwegian. Reasons for the consultation and other symptoms presented were noted as From the Depanmem of Nursing Science, and the Institute of Community Medicine, Universityof Tromsr Norway, and the Department of Advanced Nursing, Umed University, Sweden. Address reprintrequests to VeniceSCrlie, RNT, MSc, Department of Nursing Science, MH, Breivika, 9037 Tromsr Norway. Copyright 9 1996 by W.B. Saunders Company 0882-5963/96/1105-001353.00/0 337
338
SORLIE, MELBYE, AND NORBERG
RESULTS
key words, as well as the advice given. The parents' descriptions of the problems were afterwards classified in accordance with the International Classification of Primary Care system (ICPC). The advice given was classified as: observation, medication, nursing care, and advice about eating and drinking. The outcome of the consultation was assigned to one of the following three categories: (1) home visit by doctor, (2) visit to the emergency ward immediately or later the same day, and (3) advice to observe the child at home. The data were analysed using the Statgraphics software program (Bitstream, Inc., Cambridge, MA).
A total of 152 telephone consultations were registered. Of those who called, 113 (74%) were mothers, 35 (23%) fathers, two were grandmothers, one was an uncle, and one an employee at an institution. In this article they will all be labeled 'parents'. Half of the children were younger than 4 years of age (Figure 1) and 53% were boys. All in all, 37 symptoms were registered. Fever was the symptom most frequently presented. In 78 eases, (51%) fever was the first symptom that the parents mentioned. The 10 most frequent symptoms reported by the parents are shown in Table 1. As a result of the consultation, 18 children (12%) were visited by a doctor. Fifty-six parents (37%) were advised to take the child to the emergency clinic the same day, which they did. In 78 cases (51%), the parents were advised to observe their child at home. Additional advice was given to all parents and is shown in Table 2. In 18 of the 78 cases in which parents were advised to observe their child at home, the parents contacted the emergency clinic again during the next week, and medical treatment was prescribed for 10 of the 18 children (Table 3). In 9 cases antibiotics were prescribed: of these, 7 children were diagnosed as having otitis media, one with tonsillitis, and one with acute bronchitis. After 1 week, 10 of the 18 patients had recovered completely, and 8 were better or much better. The mean duration of the telephone consultations was 4.1 minutes (range, 1 to 10 minutes), compared with 4.3 minutes when the child was
Interviews
One week after the consultation, the parents who were advised to observe their child at home were telephoned and asked about the course of their child's illness. Parents who had made a subsequent contact with the emergency clinic or primary health care in the interim period were asked only about the child's recovery. Outcomes of later consultations were registered from medical records. The parents who neither called again nor visited the emergency clinic within 1 week were interviewed by the first author, who used a structured interview format. All questions could be answered with yes or no, but further spontaneous explanations were invited. Consensual validation was obtained by repeating each question and answer. The yes/no answers were counted. The spontaneous commentaries were listed and classified. The study was approved by the Regional Committee of Medical Research Ethics, Troms0. 30
25
20
No. of children
15
10
0 -~--m[~-1
Z
3
4
5
6
7
8
9
10
Years of life
11
12
13
14
15
16
Figure 1.
Distributionofyears
o f life in 152 children with acute
illness.
TELEPHONE COUNSELING PARENTS OF CHILDREN
339
Table 1. Frequency of Symptoms
Table 3. Time From Telephone Consultation to Treatment
Frequency of Symptom (%}
Frequency of Symptomas First Mentioned (%)
Delay Between TelephoneConsultation and Attendance~Visit
Attended the Clinic
Fever Cough Sore throat Other respiratory symptoms Fatigue/malaise Rash/itching Head ache
59 22 11 18 18 12 10
51 7 3 7 3 9 3
<1 day 1 day 2 days 4 days
5 7 1 3
Nausea~vomiting
11
1
Ear symptoms Accidents
11 7
7 7
178
100
To~I
1 1 ---
Medical Treatment Prescribed 3 4 1 2
NOTE. Registrations from the medical records at the emergency clinic of 18 sick children advised to be observed at home, but who later came to the ward or were visited by doctor. Delay between telephone consultation with the nurse and attendance/ visit, and prescription of medical treatment is listed.
NOTE. Frequency of the 10 most common symptoms of 152 children with acute illness described by parents calling an emergency ward, and the frequency with which each were the first symptom mentioned by the parents.
visited by a physician at home, 3.2 minutes when the child came to the emergency ward the same day, and 4.8 minutes when the parents were advised to await developments at home. Of the 60 parents who had neither called nor visited the emergency clinic after the telephone consultation, 58 were interviewed about the satisfaction with the service. Fifty-four of these had called the emergency clinic without having previously consulted anyone else. Sixteen parents (28%) had no one to ask for advice, and reported frequent contacts with the emergency ward for advice. All the parents reported having followed the advice given. All 58 children had improved or had fully recovered. The parents' answers to the yes/no questions about their satisfaction with the advice revealed that 54 parents (93%) thought that the advice was satisfactory. 52 parents (90%) thought that the advice had been helpful to the child. 44 parents (76%) had learned new things. The parents' spontaneous comments showed more specifically what they valued: Table 2. Advice Given to the Parents of the 152 Children
Special observation (such as loss of appetite, fever, level/type of pain) Medication (analgetics/antipyretics was recommended in 72) Nursing care (such as keeping the child in bed, oral care and reducing itching} Food and fluid (particularly fluid in connection with fever)
Visited by Doctor at Home
N
%
119
78
113
74
69
45
58
38
54 parents (93%) sought confirmation of care measures already taken. The advice had given them a feeling of security. 43 parents (74%) felt reassured when encouraged to call back or visit the emergency ward if the child's illness should change for the worse. 54 parents (93%) praised the nurses for their good performance. They emphasized the nurses' professional skills as well as their social skills. Most often they commented on both aspects in the same statement and did not specify one of these aspects to the detriment of the other.
DISCUSSION The high frequency of satisfied parents found in this study might have been lower if the parents who had made a subsequent consultation with the emergency clinic had been interviewed. It was thought that these parents would have difficulties in discriminating between the differing sources of advice and therefore would answer questions about the first telephone consultation inappropriately. The fact that all 18 parents took their child to the emergency clinic, and not to a general practitioner, indicates that most of them found the advice given to be reasonable. They had probably, as with the interviewed parents, been encouraged to take the child to the clinic if the child's condition deteriorated. The fact that most interviewed parents were satisfied with the advice given was probably connected with three factors that they mentioned. First, all children had recovered or improved. This could have been spontaneous and unrelated to the advice given or the care measures undertaken. Second, the encouragement by the nurses to contact them again if necessary made the parents feel secure. Third, almost all parents (93%) wanted confirmation of care measures that they had already under-
340
taken. In fact, 45 (75%) of the parents said that they often called the emergency ward. Many of these needed confirmation, as they felt uncertain about their own competence. The nurses could confirm the parents' understanding of the situation by expressing the same judgment, thereby promoting a sense of safety and security, strengthening the courage to act and share responsibility for the sick child's management. Parents need to have their actions confirmed by health care personnel and this is highlighted in an American study (Stamp & Kreusser, 1990). The telephone counseling of parents with sick children reduced the number of physicians' consultations, and parents expressed positive feelings about not having to visit the hospital. The parents also derived satisfaction from being able to treat their sick children. Therefore, it seems reasonable to assume that such confirmation and the easy access to the nurses was particularly important for the 16 parents (28%) who had no one else to ask for help. In an American study, Rauen (1985) described that most of Cope-line's callers either seek information or need to relieve stress rather than to resolve crises or emergencies. The philosophy of the parents' Cope-line is to support and help parents to "cope" with the situation. They frequently gain renewed inner strength and self-confidence. This correlates strongly with what the parents in this study said spontaneously. Fever was the most common symptom in this study. Children between 6 months and 3 years of age often contract infectious diseases with fever (Sherman, 1990; Jones, Maestri, & McCoy, 1993), and parents often make consultations concerning small children (Rutle, 1983). Therefore, it was not surprising that such an amount of the telephone counseling sessions concerned small children with fever. The mean duration of the telephone consultations (4.1 minutes) was similar to that found in other studies. In a Swedish investigation, the mean time, registered at six different health centers, ranged from 2.9 to 4.1 minutes (Marklund & Bengtsson, 1988). In a study from the United States, the consultation with nurses lasted for an average of 5 minutes (Moreland & Grier, 1986). The nurses at the emergency clinic meet a great number of sick children every day, and thus have great experience in assessing and prioritizing the severity of their illnesses. Their role has a focus similar to that of nurse practitio-
SORLIE, MELBYE,AND NORBERG
ners who focus on physical assessment, health promotion, and management of common pediatric problems (Keefe & Biester, 1993). They are also experienced in counseling parents of sick children over the telephone. In a British study, 41% of the out-of-hour calls were for children (McCarthy & Bollam, 1990). The nurses' experience may be important in explaining the parents' satisfaction. However, the small number of contacts in our study (152) does not permit an assessment of the risk of more or less serious errors, such as undertreatment of severe bacterial infection. The nurses are able to offer parents a home visit by a physician or can invite them to come to the emergency ward; telephone counseling is only one dimension of a broader health care service. Telephone counseling in isolation would probably not have been evaluated as positively by the parents. Telephone counseling by experienced nurses, as a complement to consultations with a doctor, may be of great value. Such counseling may be an economical and effective service that saves time and spares patients the difficulty of leaving home and undergoing medical examination, as pointed out in previous articles (Kjersgaard, Darre, & Rasmussen, 1985; Marklund et al., 1990; Stamp & Kreusser, 1990). It has also been pointed out that the costs of telephone counseling services are minimal, considering the large population that can be reached (Rauen, 1985; Elmer & Maloni, 1988). Our study showed that the nurses' telephone counseling mainly concerned medical matters such as special observation and medication. However, this does not automatically mean that the nurses acted only as less educated physicians. It seems reasonable to assume that their medical counseling was influenced by their nursing knowledge and experience. This question needs to be illuminated in future research.
CONCLUSION Most of the parents who were given telephone advice by a nurse on observing and taking care of their sick child did not need a second opinion, and they greatly appreciated the encouragement, the confirmation, and the information given to them by nurses.
ACKNOWLEDGMENT We are indebted to the nurses who participated in the study, and to the Tromsr Community for economic support.
TELEPHONE COUNSELING PARENTS OF CHILDREN
341
REFERENCES Bhopal, J.S., Bhopai, R.S. (1988). Outcome and duration of telephone consultations in a general practice. Journal of the Royal College of General Practitioners, 38, 566. Borchgrevink, C.F., Bruusgaard, D. (1981). Telefonkonsultasjon som alternativ til akuttsykebes~k. (Telephone consultation as an alternative to house calls from a physician). Tidsskrift for den Norske Leegeforening, 6, 398-401. Broome, M.E. (1986). Telephone protocols for pediatric assessment and advice. Journal of Emergency Nursing, 12, 142-146. Carnevali, D.L. (1992). Sykepleieplanlegging (Originally published 1976 under title Nursing Care Planning). Oslo: Ad Notam Gyldendal A/S. Elmer, E., Maloni, J.A. (1988). Parent support through telephone consultation. Maternal Child Nursing Journal, 17, 13-23. Jones, L.C., Maestri, B.O'B., McCoy, K. (1993). Why parents use the warm line. The ordinary worries of raising children of all ages prompt calls to a telephone counseling service. American Journal of Maternal Child Nursing, 18, 258-263. Keefe, M.R., Biester, D.J. (1993). Advanced practice in pediatric nursing. Journal of Pediatric Nursing, 8, 263-264. Kjersgaard, A.G., Darre, E., Rasmussen, O.V. (1985). Telefonr~dgivning fra en skadestue. (Telephone advice from an emergency ward). Ugeskift for L~eger, 147, 13631364. Malmberg, B.G. (1981). Telefonr~dgivning vid en v~trdcentral. V~rds6kandes attityder. (Telephone consultation at an emergency clinic. The patients' attitudes). Tumbaprojektet Report No 3, Huddinge Hospital, Stockholm, Sweden. Marklund, B., Bengtsson, C. (1988). Telefonr~dgiv-
ning--En omfattande verksamhet vid v~trdcentralerna. (Telephone advice--An extensive practice at the emergency clinics). L~kartidningen, 85, 4226-4228. Marklund, B., Bengtsson, C., Blomkvist, S., Furunes, B., G/icke-Herbst, Silfverhielm, B., et al. (1990). Evaluation of the telephone advisory activity at Swedish primary health care centres. Journal of Family Practice, 7, 184-189. McCarthy, M., Bollam, M. (1990). Telephone advice for out of hours calls in general practice. British Journal of General Practice, 40, 19-21. Moreland, H., Grier, M. (1986). Telephone consultation in the care of older adults. Geriatric Nursing, 7, 28-30. Otterstad, H.K. (1991). Legevakt i allmennlegetjenesteni Vestfold. (An emergency clinic in primary health care in Vestfold county). Tidssknft for den Norske Lzegeforening, 111, 1749-1751. Rauen, K. (1985). The telephone as stethoscope. American Journal of Maternal Child Nursing, I0, 122-124. Rutle, O. (1983). Pasienten fram i lyset--Analyse av legekontaktar i prim~erhelsetenesta. (The patient in focus-Analyses of consultations by physicians in primary health care). SIFF-rapport No 1/1983 Oslo: Statens institutt for folkehelse, gruppe for helsetjenesteforskning. Rytter, E.C. (1989). Legevakt i en storby. (An emergency clinic in a big city). Tidsskrift for den Norske Laegeforening, 109, 2539-2543. Sherman, W.G. (1990). What can I do when my child has a fever? Children's-- The Magazine of St. Louis Children's Hospital 1, 6. Stamp, B., & Kreusser, K.L. (1990). New answer line helps fill the parent information gap. Children's--The Magazine of St. Louis Children's Hospital, 1, 3-6.