Real nursing? The development of telenursing

JAN ORIGINAL RESEARCH Real nursing? The development of telenursing Helen A. Snooks, Anne M. Williams, Lesley J. Griffiths, Julie Peconi, Jaynie Rance, Sharon Snelgrove, Srikant Sarangi, Paul Wainwright & Wai-Yee Cheung Accepted for publication 31 October 2007 Correspondence to H.A. Snooks: e-mail: [email protected] Helen A. Snooks PhD Professor of Health Services Research Centre for Health Information, Research and Evaluation (CHIRAL), Swansea University, UK Anne M. Williams PhD RN Professor of Nursing Research Department of Nursing, Health and Social Care Research Centre, Cardiff University, UK Lesley J. Griffiths BSc PhD Professor of Health Policy School of Health Science, Swansea University, UK Julie Peconi BSc Research Officer Centre for Health Information, Research and Evaluation (CHIRAL), Swansea University, UK Jaynie Rance PhD C Psychol Lecturer School of Health Science, Swansea University, UK Sharon Snelgrove BSc MPhil RN Lecturer School of Health Science, Swansea University, UK Srikant Sarangi MA MLitt PhD Professor in Language and Communication Cardiff School of English, Communication and Philosophy, Cardiff, UK SNOOKS H.A., WILLIAMS A.M., GRIFFITHS L.J., PECONI J., RANCE J., S N E L G R O V E S . , S A R A N G I S . , W A I N W R I G H T P . & C H E U N G W . - Y . ( 2 0 0 8 ) Real nursing? The development of telenursing. Journal of Advanced Nursing 61(6), 631–640 doi: 10.1111/j.1365-2648.2007.04546.x Abstract Title. Real nursing? The development of telenursing Aim. This paper is a report of a study to understand the impact of telenursing from the perspective of nurses involved in its provision, and in more traditional roles. Background. Nurse-led telephone helplines have recently been introduced across the United Kingdom, a major step in the development of nursing practice. Method. A structured questionnaire was sent to all nurses working in the NHS Direct (National Health Service Direct) Wales telephone service (n = 111). Ninetytwo completed questionnaires were returned (response rate 83 per cent). Two focus groups were conducted: one with telephone service nurses (n = 8) and one with other nurses (n = 5). The data were collected in 2002. Findings. Respondents represented a highly educated workforce from a range of healthcare specialties. They reported that they joined the telephone service for improved salary and flexible working. Two-thirds reported improved job satisfaction. All focus group participants reported that the development of nursing skills was affected by the use of decision support software and the remote nature of the consultation. Participants reported opportunities for skill development, although the role could be stressful. All agreed that the service was popular with callers, but the nurses from outside raised concerns about whether telenursing was ‘real’ nursing and about the evidence base for the service and access by disadvantaged groups. Conclusion. Differences between the groups reflect policy tensions between the need to develop new nursing skills, including the use of technology, to improve efficiency and recognition of the worth of hands-on nursing. These tensions must be addressed for the telephone service to function as part of an integrated healthcare system. Keywords: focus groups, nurse roles, policy, questionnaires, telenursing, technology Introduction continued on page 2 The NHS 24-hour nurse-led telephone-based health advice and information helpline, commonly known as NHSD, was launched in England in 1998 (Department of Health 1997), and in Wales in 2000 (Gregory & Kennedy 1999). Evidence shows  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 631 H.A. Snooks et al. Paul Wainwright MS PhD RN Professor of Nursing Faculty of Health and Social Care Sciences, Kingston University and St George’s, University of London, UK Wai-Yee Cheung PhD Senior Lecturer in Medical Statistics Centre for Health Information, Research and Evaluation (CHIRAL), Swansea University, UK that educational interventions which enhance people’s sense of self-efficacy can reduce the demand for medical intervention leading to cost savings (Coulter 2003), seen as integral to the modernization of the NHS (Wanless 2002). Modernization involves the reconfiguration of professional roles, particularly at the boundary between medicine and nursing. At this boundary, as previous work has shown, substitution of nurses for doctors and the creation of new roles form part of a workforce reconfiguration strategy. This strategy has been used in the united kingdom (UK) and internationally to meet changing patient expectations, rising costs and skills shortages (Sibbald et al. 2004, Hyde et al. 2005). From this perspective NHSD, insofar as it may redirect patients from doctors to nurses, can be seen as part of a wider effort to control access to care (Charles-Jones et al. 2003a) and as having consequences for patients, doctors and nurses. Background A telephone advice service represents a break with traditional forms of delivering nursing care, and is increasingly being used in a range of developed countries (Lattimer & George 1996), from Australia (Turner et al. 2002) and New Zealand (St George & Cullen 2001), through Denmark (Christensen & Olsen 1998), Sweden (Marklund & Bengtsson 1989) and the UK (Department of Health 1997), to Canada (Lafrance & Leduc 2002) and the United States of America (Barber et al. 2000). Telenursing has been explored in a preliminary way in general practice (Charles-Jones et al. 2003b) and community nursing (Wilson & Williams 2000). However, there is still much work to be performed to understand telephone-based clinical decision-making processes and nursing practice issues. Pettinari and Jessop (2001) explored the impact of NHSD on nursing, and looked at how the absence of visibility is managed through the development of assessment skills based on professional knowledge and experience, compensating for not being able to see patients. They identified three broad areas in which nurses anticipate and manage absence of co-presence: (1) gathering information, (2) delivering information, advice and reassurance (3) building trust and rapport. Central to the reasoning process is ‘picture building’, in which both the person and the pathology are visualized (Edwards 1998). To do this, nurses elicit the presence of physical signs and symptoms by asking specific questions about, for example, the presence of a rash or a level of pain, but they also try to build a picture of the client as a person and their environment. The nurse is dependent on the quality and accuracy of the information provided, which requires that the caller gives the information in a way that allows the nurse to understand and visualize the caller’s situation. Outcomes of assessments made over the telephone by nurses vary (O’Cathain et al. 2003, 2004), and nurses feel 632 ambivalent about telephone work, with some expressing enhanced levels of satisfaction and others concerned about the lack of what they perceive to be ‘hands-on nursing’ and the ‘monotony’ of working in a call centre (Knowles et al. 2002). The impact of the recruitment of nurses by NHSD on other services has been assessed (Morrell et al. 2002). However, the views of nurses in the wider NHS workforce about the impact of NHSD have not been researched in any systematic manner. The study reported here was the first opportunity to compare the views of two groups of nurses, working within and outside of the service, about the impact of NHSD Wales (NHSDW). The study Aim The aim of the study was to understand the impact of telenursing from the point of view of nurses involved in its provision, and those in more traditional roles. Design The work was conducted in two phases. Phase 1, a survey of nurses working within NHSDW, focused on recruitment, reasons for joining the service and job satisfaction. The focus groups undertaken in Phase 2 concentrated on issues arising from the survey related to the development of nursing practice and clinical decision-making. Participants All NHSDW nurse advisors were invited to participate in the study by responding to the questionnaire survey and by joining a focus group discussion. In addition, a purposive sample of nurses working outside NHSD was invited to  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd Development of telenursing JAN: ORIGINAL RESEARCH participate through a second focus group. Full details of respondents are given below. Data collection Phase 1 NHSDW nurse survey The questionnaire used to survey nurses working for NHSDW was closely based on that originally developed for use with NHSD nurses in England (Knowles et al. 2002). The three-page questionnaire, which included both structured items and open-ended questions, was distributed to every nurse advisor working in the three NHSDW sites in Wales via team managers and then through the internal mail system in October 2002. Completed questionnaires were returned in reply-paid envelopes direct to the research team via the general postal system. After 3 weeks the nurse advisors were reminded by the training and development manager to return their questionnaires if they had not already performed so. Assurances of confidentiality and anonymity were reinforced. Finally, follow up questionnaires were distributed 1 month after the first distribution of questionnaires. Completed questionnaires were identified by a randomly assigned number for analysis. Phase 2 focus groups Two focus groups were held, one with NHSDW nurses and one with non-NHSD nurses. Participants for the first group were recruited through advertisements across NHSDW sites. The second group was recruited purposively, through professional contacts, to include nurses in Wales from outside NHSD with a mix of backgrounds and levels of seniority. Groups were facilitated by senior researchers from the research team, with research team observers present to take notes. Topic guides for the focus groups were developed from the project brief, the literature about NHSD, and responses to the questionnaire survey. Because participant numbers were small, we undertook to ensure that the nurses could not be identified from the quotations reported. We have not therefore coded speakers, but have been careful to select quotations from a range of participants, and highlighted areas of consensus or disagreement. Ethical considerations The study was approved by the appropriate Research Ethics Committees. All participants were given information about the study and were assured that individual identities would be protected in all reported findings. Focus group participants were asked to sign consent forms at the outset of discussions. Data analysis The survey data were coded and analysed using an Access database and Statistical Package for the Social Sciences (SPSS ) Version 11 for Windows (SPSS Inc., Chicago, IL, USA). Comparisons were made with national data using the chi-squared test for differences in proportions. Responses to the open-ended questions were thematically analysed. Focus group transcripts were analysed inductively to identify themes, which were then discussed, amended and agreed among team members to ensure that key themes or points had not been overlooked or misinterpreted. Results Nurse survey A response rate of 83% was achieved (92/111), although not all respondents answered every question. The large majority of NHSDW nurse advisors were women, of British/Welsh nationality and aged between 28 and 43 years. The workforce was highly experienced, with a mean of 18 years’ (range: 2–39 years) experience in a variety of NHS specialties (Table 1). Comparison with published data on the demographic profile of the Welsh nursing workforce (Royal College of Nursing 2005) indicated that nurses working in NHSDW were educated to a higher level. Fifty-four per cent of NHSDW nurses had a Bachelor’s or higher degree, compared to 17% for all nurses in Wales (P < 0Æ001). There were no statistically significant differences in the percentage of male nurses (NHSDW: 9%; Wales: 7%, P = 0Æ65) or in the percentage of minority ethnic nurses (NHSDW: 1%; Wales: 5%, P = 0Æ20). Most respondents cited opportunities for improved salary (81Æ9%, n = 68), flexible working (80Æ2%, n = 65) and promotion (65Æ0%, n = 52) as reasons for joining the service. Two-thirds reported improved job satisfaction since joining the service (n = 61, 68Æ5%) although a minority (n = 15, 16Æ8%) reported that this had worsened. Responses to a concluding open-ended question (see Table 2) generally indicated high levels of job satisfaction, with the challenges and the development of new skills cited as rewarding. However, the degree of surveillance and audit was found to be stressful. Working hours were found to be less flexible than expected, respondents reported missing ‘handson’ nursing and monotony was reported by some to be a problem. Several respondents offered positive free-text comments about the management style of the new service. Overall, these findings were similar to those previously reported (Knowles et al. 2002), although they seem to  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 633 H.A. Snooks et al. Table 1 Characteristics of respondents to nurse survey n (%) Gender (n = 89) Female 81 Male 8 Nationality (n = 83) British/Welsh 82 Indian 1 Age (n = 65) 21–27 years 6 28–43 years 54 44+ years 5 Worked for National Health Service (NHS) prior to 87 working in NHS Direct Wales (n = 91) Professional qualifications (n = 91) Registered General Nurse – Adult 74 State Registered Nurse* 12 State Enrolled Nurse* 9 Registered Mental Health Nurse 4 Registered Nurse 4 Registered Nurse – child 9 Midwife 16 Education (n = 92) Diploma level qualification 26 Bachelor’s degree 25 Master’s degree 5 Specialty prior to working for NHS Direct Wales (n = 86) Accident and emergency/walk-in Centre 11 Community/general practitioner 10 Midwifery 10 Paediatrics 9 Intensive therapy unit/critical care 9 Surgery 6 Medicine 6 Gynaecology 3 Plastics 3 Miscellaneous (health visiting; theatre; nursing home; 19 oncology; mental health; ophthalmic; elder care; other) (91Æ0) (9Æ0) (99Æ0) (1Æ0) (9Æ2) (83Æ1) (7Æ7) (95Æ6) (81Æ2) (13Æ2) (9Æ9) (4Æ4) (4Æ4) (9Æ8) (17Æ5) (acute medical admissions) and a midwife. This focus group was held at a university site. In addressing the study aim, discussions fell into two broad areas: challenges and stresses and development of nursing practice. The findings are presented according to these broad areas, and by theme within each area. Challenges and stresses Nurses in both groups discussed areas of challenge as well as important benefits related to working within NHSDW. Theme 1: not being with the patient. Although the remote nature of the consultation was seen to offer an opportunity to develop new skills, it was also seen as being a source of stress, in part because of the lack of visibility, and also because of the lack of opportunity to follow up callers: Non-NHSD nurse: ‘…although we find as nurses it’s easier to do face-to-face [nursing], it’s actually much more difficult to do at a distance’. (28Æ3) (27Æ2) (5Æ4) NHSDW nurse: ‘…hands on and also the closure…that you don’t get and that a lot of nurses miss, certainly initially, till they get used to it…you don’t know whether the caller is going to take your advice or (12Æ8) (11Æ6) (11Æ6) (10Æ5) (10Æ5) (7Æ0) (7Æ0) (3Æ5) (3Æ5) (22Æ1) not’. NHSDW nurses raised the issue of stress related to their work from several different aspects. Calls made by people with mental health problems were consistently brought up as being of concern, as exemplified by the following quotation: NHSDW nurse: ‘I think a lot of mental health calls particularly, you know, …you’re frightened of saying too much in case you’re gonna kind of open [something] you can’t deal with’. *The term State Registered/Enrolled Nurse was an earlier term for Registered/Enrolled Nurse. indicate a more positive relationship between front-line advisors and managers in Wales. Calls for children were also cited as causing anxiety: NHSDW nurse: ‘Children definitely generate a worry…because you’ve got to rely solely on what the carer is telling you’. NHSDW nurse: ‘…disclosure and consent and all those issues around child protection can be very stressful’. Focus groups The first group, of nurses working in NHSDW as nurse advisors, was held at one NHSDW call centre, with video links to the other two study sites. Four nurses from one centre, three from the second and one from the third participated in the discussion. The second, non-NHSD, group included a district nurse, a health visitor, an accident and emergency service nurse manager, a nurse practitioner 634 Calls identified as needing an emergency response were also stressful: NHSDW nurse: ‘…persuading some callers that they do need an ambulance because…the system and your clinical skills have told you that it’s an urgent call and they’re saying…no I don’t want one, …so that’s generating stress in you ‘cos you know there’s not much time really and you try to use your skills to persuade them why, without panicking them’.  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd Development of telenursing JAN: ORIGINAL RESEARCH Table 2 Examples of answers given in response to request: ‘Please make any other comments about working for National Health Service (NHS) Direct Wales’ Theme Respondent Quotation Job satisfaction W9 W2 I feel totally different since working here; more relaxed definitely, more valued and supported Since joining NHS Direct it is not what I expected…working for NHS Direct is very rewarding and a tremendous learning curve There are tremendous opportunities within this expanding service to expand your knowledge base Not keen on the controlling aspect…was assured that the service was run with a ‘no blame’ culture – this is definitely not the case I have found the environment intense and claustrophobic. Feel an undue pressure from management, media, callers and politics…I have found this job to have worn me out, close to burn out I find the reality of working for NHS Direct Wales does not meet the pre-interview promises. Family working is not as flexible as I had hoped …there is little, if any opportunity to maintain clinical skills in working hours One can become clinically deskilled because of long periods away from clinical placements Working 37Æ5 hours per week at a pod does not give complete job satisfaction. Nurses need to have input into other areas…to relieve monotony An enthusiastic service with lots of support from managers The atmosphere is very good and the managers very approachable W29 Surveillance/audit W55 W85 Flexibility of hours W64 Hands-on nursing Monotony W64 W14 W16 Relationship between nurses and managers W81 W9 Theme 2: contact with patients at individual level. One-to-one contact with callers was described at various times during the NHSDW nurse focus group, as stressful: NHSDW nurse: ‘Working with colleagues that are coming in new all NHSDW nurse: ‘…and whilst you’re working, it’s just you and the The variety of the role was commented on positively by several participants: caller…it can be quite isolating I think. You can spend your whole shift just talking to callers and the calls are quite intense, one after the other, you end up quite strained mentally’. the time from different disciplines also gives you the chance to find out what’s current and also gives you a lot of satisfaction…’. NHSDW nurse: ‘I feel in the last 2 years that I have been here it’s certainly helped my personal development because of the job being However, they could also be satisfying: varied…and very challenging’. NHSDW nurse: ‘…being able to have a one-to-one, so often in a Theme 4: reduced physical demands. The benefits of a less physically-demanding role were recognized by nurses in both groups: ward situation you might have eight or ten young children…and you could rarely have a one-to-one with any of them, ‘cos there was always someone wanting something else…being able to totally give that caller the time that they need’. NHSDW nurses reported that they gained satisfaction from the relationship they built up with callers, particularly when they received feedback from them. Some nurses managed to reconstruct the experience of call centre nursing to provide them with ‘closure’ or continuity, where thanks from patients might be seen as a proxy for the ongoing relationship with patients: NHSDW nurse: ‘Most people will say thanks, and they find it helpful at the end of calls which is probably a greater satisfaction rate than you have on a day-to-day basis in other aspects of nursing’, Theme 3: generic setting. The challenge of answering difficult questions and working with nurses from a range of backgrounds was welcomed: Non-NHSD nurse: ‘The workload is at a different pace, and you can only race up and down the wards, can’t you, for so many days in a year without getting physically exhausted’. NHSDW nurse: ‘Your feet don’t ache any more!’ Development of nursing practice Theme 1: development of new communication skills. A central feature of telephone nursing is the lack of visibility, because of the remote nature of the consultation. This has an impact on the skills required to assess and give advice. However, it also brings opportunities; in particular the opportunity to develop new communication skills was recognized by nurses working within NHSDW and those outside: NHSDW nurse: ‘You ask the (mother) questions and she’s interpreting it in her own way…and what she’s asking the child is completely  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 635 H.A. Snooks et al. different to what you’ve asked her…it’s constantly rewording it and NHSDW nurse: ‘I worked in intensive care before and when acutely listening perhaps what they are passing on to the child and somebody is described as being grey, cold, clammy, you know, what the child is saying back to then and the different way they’ll say straightway you know that they’re probably quite poorly…you’ve the response back to you’. got this picture from past experience which you can build on and ask Non-NHSD nurse: ‘I think I would welcome somebody coming back in with…customer care skills that maybe people were never taught…’. NHSDW nurses emphasized the centrality of communication skills and relationship- building in telephone-based encounters. Encouraging interaction and empathy were described as important, demonstrating coherence with professional ideology: NHSDW nurse: ‘I think it’s important to build up relationship with them quite quickly and build up the trust, you know, and empathy so that you can get the best for that caller’. the relevant questions’. These nurses clearly felt ownership and responsibility for decisions made, despite the use of decision support software: Facilitator: ‘So, at the end of the consultation, who has made the decision, is it a nursing decision or is it a computer decision?’ (All NHSDW nurses): ‘Nursing decision’. NHSDW nurse: ‘Yeah, because if you’d have any doubt of the disposition, you would change it…you could discuss, but it’s still your call if you’ve taken it and you’re the one who decides’. Theme 2: risks of telenursing. Potential pitfalls of remote nursing were also described: know, …can send us to wrong conclusions’. Theme 4: changing role of nurses. Perceptions of the public as well as those within the profession were discussed when questioning the identity of NHSD nurses as ‘real’ nurses by the non-NHSD nurses: Non-NHSD nurse: ‘It dehumanizes the way we are living and I would Non-NHSD nurse: ‘I just wonder what the public’s perception is, do much rather, it’s much more than talking to somebody when you can they realise that there is a nurse at the end of the phone or do they see them, it’s the body language, it’s the reaction, it’s something other think it’s just a call-person?’ NHSDW nurse: ‘It’s very much about picture building, which, you than just hearing the words’. Another nurse in the non-NHSD group felt that the remote nature of the call necessarily limited the consultation: The role of telenursing was discussed by non-NHSD nurses in the context of wider changes in the role and identity of nurses: Non-NHSD nurse: ‘Although I think NHSD staff would say that they Non-NHSD nurse: ‘I suppose historically you think of nurses as use their personal skills and experience, I think away from the face- people by the bedside, doing the hands-on, but…there are so many to-face consultation it is easy to be…even more task-oriented’. that aren’t [doing] that sort of thing’. The reference to task orientation carries within it a powerful coded criticism which claims a more positive value for faceto-face contact within the professional ideology of nursing, and equates remote nursing with technologized or depersonalized care. Theme 3: real nursing? The contrast between the face-to-face provision of care in a traditional manner and care by telephone raises a dilemma, perhaps best encapsulated by the ways in which non-NHSD nurses questioned whether NHSD nursing is real nursing. They went on to suggest that nurses might lose their all round skills whilst working at NHSD: Related to this was the increasing role of nurses as gatekeepers to care: Non-NHSD nurse: ‘Nurse practitioners in the primary care setting are doing more…referring patients to hospital and is that going to happen to NHSD? Are they going to be seen more as the gatekeepers to acute sectors of the health service?’ Theme 5: value of the service. Nurses within NHSDW were clear that the service was successful in empowering patients for the future: NHSDW nurse: ‘I think it’s needed because the public needs to some degree learn self-empowerment and how to take their health Non-NHSD nurse: ‘There is a place in NHS[D] for nurses who in their own hands when it’s appropriate and we’re there to guide perhaps, there are nurses who don’t really want to nurse people’. them’. However, NHSDW nurses were clear that they depended on their nursing experience and knowledge to carry out their new role: Non-NHSD nurses agreed to some extent that the service might play a role in empowerment but conditioned this evaluation by emphasising the limits of the service: 636  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd Development of telenursing JAN: ORIGINAL RESEARCH Non-NHSD nurse: ‘There are very positive sides…information is Non-NHSD nurse: ‘The people that NHSD send to us…. I don’t power for the patient and relative, it enables them to go to other sites know whether they would have come anyway, and I don’t know the of the health service to gain what they want’. number who haven’t come – but there are people who come, who are Non-NHD nurse: ‘It does arm patients with information, but…that is going to be limited to a group of patients’. Although not specifically asked about issues of access, nonNHSD nurses repeatedly raised concerns about the appropriateness of a telephone-based service to the needs of people in some disadvantaged groups: Non-NHSD nurse: ‘My experience of the impact of NHSD…was that with people like from ethnic groups it actually widened…inequalities in health because people did not have access to a telephone and they didn’t have the skills for a long consultation…it was the value of the nurse in a face-to-face consultation that was guiding that patient through the healthcare system’. Non-NHSD nurse: ‘To ask people who’ve been through a very traumatic life to go on to a telephone conversation is asking too much of people who are homeless’. Non-NHSD nurse: ‘Is it more accessible to middle class type England than it is to…the ordinary working class…’. sent by ambulance…and there are people who just walk in’. NHSDW nurse: ‘I don’t see…much joining up of the whole healthcare system’. Discussion Study limitations Findings from two focus groups can only give a glimpse of the views of nurses working inside and outside NHSD; nevertheless, the discussions provided some initial insight into the views and concerns of nurses about NHSD in Wales. We do not have information about the experience of nurses in the non-NHSD group of giving telephone advice, although this might have influenced their views. It would be useful to repeat the focus groups in Wales and in other NHSD services in the UK to confirm (or otherwise) our findings and to explore further areas of difference and their implications. Non-NHSD nurse: ‘I’m not sure what this expensive service is actually doing for the major users of healthcare, older people… In contrast, none of the NHSDW nurses acknowledged any concern about the applicability of the service to different groups. The only comment about access was made with the converse point: NHSDW nurse: ‘…wants a chat, it’s quite satisfying to know that we are there for them and accessible. It’s the main thing to be accessible’. Non-NHSD nurses raised other concerns related to the value of the service. They specifically questioned the evidence on which its introduction and development had been based: Non-NHSD nurse: ‘…whether [NHSD is] going to expand by stealth as opposed to extend from evidence of effectiveness and…’. Several times they raised the issues of opportunity cost, for example: Non-NHSD nurse: ‘…and if that money had been put into the wards you could have upgraded, given them an F grade on the ward for their experience, how much better that would have been’. Theme 6: operating as part of a system. Finally, both groups expressed concerns about the impact of NHSD on the healthcare system, and its integration with other parts of the system: Interpretation of findings A striking aspect of these findings is the way in which both groups of nurses drew on a shared ideology of professional nursing to justify quite different positions in relation to a technological development, telenursing. In part this is due to the dilemmas generated by policy pressures, which emphasize and place positive value on conflicting positions. Nurses are expected to adapt, expand roles and acquire new technological expertise to deal with increasing numbers of patients more efficiently. At the same time they are exhorted to put the patient at the centre of everything they do and to work alongside patients to deliver individually tailored care based on a holistic relationship (Latimer 2000). Both groups of nurses in our study were at pains to claim for themselves the identity of ‘real’ nurses. The differences between remote nursing and face-to-face nursing reflect the dilemma of making standardized care available to greater numbers of patients whilst increasing the patientcentredness of individual consultations and care. Whilst the RCN definition of nursing (Royal College of Nursing 2003) is broad enough to include care that is delivered remotely, it is clear from our focus groups that this conflict has not yet been comfortably resolved, at least for these participants.  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 637 H.A. Snooks et al. What is already known about this topic • National Health Service Direct is a popular service with callers, although nurses in the service describe their work in both positive and negative terms. • Nursing by telephone requires the development of different skills from face to face nursing. • Assessment and communication skills are particularly important in telenursing. What this paper adds • Nurses working within and outside the telephone-based helpline agreed that telenursing offers opportunities for skill development and job satisfaction. • Nurses from outside the service questioned whether nursing by telephone constitutes ‘real’ nursing, the effectiveness of the service and the evidence base for its implementation. • Differences between groups reflect wider tensions in nursing that need to be addressed in order for the service to function as part of an integrated system for unscheduled health care. Thus, NHSDW was described on the one hand in positive terms - as having provided opportunities for promotion and skill acquisition and development, with attractions cited as the role being physically easier than hands on nursing and its innovative character. The remote nature of the consultation was discussed as being an opportunity yet also stressful. On the other hand, the remote nature of the consultation and use of decision support software were acknowledged to affect the provision of the service and the development of nursing skills, both positively and negatively. In particular, views differed between NHSDW nurses and those from outside the service in terms of whether telenursing is ‘real’ nursing. These more negative aspects of remote nursing were countered by nurses working within the service, who described high levels of job satisfaction and cited relationships built with callers, the availability of expertise from a range of colleagues, and the variety they of the work. All agreed that communication skills needed to be highly developed in the telephone-based encounter. However, there was a difference between NHSDW and non-NHSD nurses with regard to the value of the service. Whilst all agreed that it was popular with callers, nurses from outside NHSD questioned the evidence-base for the implementation 638 of the service and whether the money was best spent in this way. Access issues were raised by the non-NHSD nurses in relation to minority ethnic groups, lower socioeconomic groups, homeless and older people. These concerns have been raised many times [George (2002), National Audit Office. NHS Direct in England (2002)] and in several recent reports of empirical studies (Burt et al. 2003, Cooper et al. 2005, Knowles et al. 2006). NHSDW nurses were generally very positive about their working environment and the satisfactions they derived from their work. They talked about the satisfaction they got from their one-to-one consultations, and were unanimous in reporting that they relied on their nursing skills to carry out the role. They also were in agreement that the service was worthwhile, although they were only able to back this up by describing caller satisfaction and empowerment in very broad terms. In common with telephone nurse advisors working in Sweden, they reported stresses related to lack of visual contact with patients and maintaining clinical skills (Wahlberg et al. 2003). By contrast, although the non-NHSD participants acknowledged the opportunities that nurses were offered within NHSD, there was consistent scepticism about the value of the service and the political context for its introduction. Policy concerns identified by our participants – inequalities in health, equality of access to services, and evidence based practice – were used by non-NHSD nurses to strengthen an argument against ‘remote’ nursing. The double criticism highlighted by comments made by this group was that not only is NHSD failing to provide ‘real’ nursing but that it also fails to tackle many important current policy concerns. Conclusion Our findings reflect difficulties currently faced by the nursing profession. Conflicting policy demands and expectations, both from the public and within the profession, mean that nurses are expected to acquire and work with traditional nursing values (Wimpenny 2002); however, at the same time, the pressures of increased demand which NHSD attempts to tackle have led to a tight management style and standardized computer decision software that can be seen to contribute to a loss of traditional nursing skills. At one level, then, it is no surprise to find nurses supporting competing versions of what ‘real’ nursing might be in practice. Our findings suggest there may be a rift between nurses working within and outside the service. If NHSD, as policy direction indicates (Department of Health 2001), is to truly form an integrated part of the healthcare system, these gaps between those inside and those  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd Development of telenursing JAN: ORIGINAL RESEARCH outside the service in perception of the role and its worth will need to be addressed. Issues of access and concerns about cost-effectiveness need to be addressed through research, practice and service development. More split roles, for instance working part of the time for NHSD as a nurse advisor and part of the time giving care in a face-to-face context, and joint working across services might increase understanding and appreciation of the attractions, stresses and value of the delivery of nursing through this remote route. Author contributions HAS, AMW, SSa, PW and WYC were responsible for the study conception and design and HAS and LJG were responsible for the drafting of the manuscript. 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