Amanda J Ullman: Dr Ullman conceptualized and designed the study, drafted the initial manuscript, and approved the final manuscript as submitted.
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Gabor Mihala: Mr Mihala assisted with the conception and design of the study, led the acquisition and analysis of data, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Nicole Marsh, Christine Woods and Claire Rickard: Ms Marsh, Ms Woods and Dr Rickard assisted with the conception and design of the study, interpretation of the data, reviewed and revised the manuscript for important intellectual content, and approved the final manuscript as submitted.
Kate O’Leary: Ms O’Leary assisted with the acquisition of data, drafting the initial manuscript, critically reviewed the manuscript and approved the final manuscript as submitted.
Simon Bugden and Mark Scott: Drs Bugden and Scott were clinical leads for the IVL-GONE study, contributed to the acquisition of data, reviewed and revised the manuscript, and approved the final manuscript as submitted.
All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
CONTRIBUTION OF THE PAPER What is already known on this topic?
The skin surrounding vascular access devices is exposed to irritation and trauma, associated with device management, resulting in complications such as bruising and dermatitis.
The incidence of these complications, and the risks associated with their development have not previously been clearly estimated.
What does this paper add?
Significant skin complications frequently develop around peripheral and central vascular access devices, with bruising, infiltration and dermatitis the most common.
Risk factors were mostly associated with device (e.g., peripheral device placement) and patient (e.g., increasing age, co-morbidities) characteristics, rather than management (e.g., dressings).
References
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Edwards, M., Rickard, C.M., Rapchuk, I., Corley, A., Marsh, N., Spooner, A.J., Mihala, G., Fraser, J.F., 2014. A pilot trial of bordered polyurethane dressings, tissue adhesive and sutureless devices compared with standard polyurethane dressings for securing short-term arterial catheters. Crit Care Resusc 16 (3), 175-183.
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A Pilot Randomized Controlled Trial of Novel Dressing and Securement Techniques in 101 Pediatric Patients. J Vasc Interv Radiol 28 (11), 1548-1556.e1541.
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Kutzscher, L., 2012. Management of irritant contact dermatitis and peripherally inserted central catheters. Clin J Oncol Nurs 16 (2), E48-55.
Lau, C.S., Chamberlain, R.S., 2016. Ultrasound-guided central venous catheter placement increases success rates in pediatric patients: a meta-analysis. Pediatr Res.
LeBlanc, K., Baranoski, S., 2011. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears(c). Adv Skin Wound Care 24 (9 Suppl), 2-15.
Marsh, N., Larsen, E., Genzel, J., Mihala, G., Ullman, A.J., Kleidon, T., Cadigan, S., Rickard, C.M., 2018. A novel integrated dressing to secure peripheral intravenous catheters in an adult acute hospital: a pilot randomized controlled trial. Trials under review.
Marsh, N., Webster, J., Chan, R.J., Mihala, G., Rickard, C., 2015. Securement methods for peripheral venous catheters: A randomised controlled pilot trial. J Vasc Access 16 (3), 237-244.
Marsh, N., Webster, J., Larson, E., Cooke, M., Mihala, G., Rickard, C.M., 2018. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med 13 (2), 83-89.
Marsh, N., Webster, J., Mihala, G., Rickard, C.M., 2015. Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database Syst Rev (6), Cd011070.
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Mimoz, O., Lucet, J.C., Kerforne, T., Pascal, J., Souweine, B., Goudet, V., Mercat, A., Bouadma, L., Lasocki, S., Alfandari, S., Friggeri, A., Wallet, F., Allou, N., Ruckly, S., Balayn, D., Lepape, A., Timsit, J.F., 2015. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet.
Reynolds, H., Taraporewalla, K., Tower, M., Mihala, G., Tuffaha, H.W., Fraser, J.F., Rickard, C.M., 2015. Novel technologies can provide effective dressing and securement for peripheral arterial catheters: A pilot randomised controlled trial in the operating theatre and the intensive care unit.
Aust Crit Care 28 (3), 140-148.
Rickard, C.M., Edwards, M., Spooner, A.J., Mihala, G., Marsh, N., Best, J., Wendt, T., Rapchuk, I., Gabriel, S., Thomson, B., Corley, A., Fraser, J.F., 2016. A 4-arm randomized controlled trial of solutions for jugular central venous access device securement in 221 cardiac patients. J Crit Care 36, 35-42.
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Rickard, C.M., Marsh, N., Webster, J., Playford, E.G., McGrail, M.R., Larsen, E., Keogh, S., McMillan, D., Whitty, J.A., Choudhury, M.A., Dunster, K.R., Reynolds, H., Marshall, A., Crilly, J., Young, J., Thom, O., Gowardman, J., Corley, A., Fraser, J.F., 2015. Securing All intraVenous devices Effectively in hospitalised patients--the SAVE trial: study protocol for a multicentre randomised controlled trial. BMJ Open 5 (9), e008689.
Rickard, C.M., Ray-Barruel, G., 2017. Peripheral intravenous catheter assessment: beyond phlebitis.
Lancet Haematol 4 (9), e402-e403.
Rickard, C.M., Webster, J., Wallis, M.C., Marsh, N., McGrail, M.R., French, V., 2012. Routine versus clinically indicated replacement of peripheral catheters: a randomised controlled trial. Lancet 380 (9847), 1066-1074.
Thayer, D., 2012. Skin damage associated with intravenous therapy: common problems and strategies for prevention. J Infus Nurs 35 (6), 390-401.
Ullman, A.J., Cooke, M., Kleidon, T., Rickard, C.M., 2017. Road map for improvement: Point prevalence audit and survey of central venous access devices in paediatric acute care. J Paediatr Child Health 53 (2), 123-130.
Ullman, A.J., Cooke, M., Rickard, C., 2015. Examining the role of securement and dressing products to prevent central venous access device failure: a narrative review. J Assoc Vasc Access 20 (2), 99-110.
Ullman, A.J., Cooke, M.L., Mitchell, M., Lin, F., New, K., Long, D.A., Mihala, G., Rickard, C.M., 2016. Dressing and securement for central venous access devices (CVADs): A Cochrane systematic review. Int J Nurs Stud 59, 177-196.
Ullman, A.J., Cooke, M.L., Mitchell, M., Lin, F., New, K., Long, D.A., Mihala, G., Rickard, C.M., 2015. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev 9, Cd010367.
Ullman, A.J., Kleidon, T., Gibson, V., Long, D.A., Williams, T., McBride, C.A., Hallahan, A., Mihala, G., Cooke, M., Rickard, C.M., 2016. Central venous Access device SeCurement And Dressing Effectiveness in paediatrics: protocol for randomised controlled trials. BMJ Open 6 (6).
Ullman, A.J., Kleidon, T., Gibson, V., McBride, C.A., Mihala, G., Cooke, M., Rickard, C.M., 2017.
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Ullman, A.J., Marsh, N., Mihala, G., Cooke, M., Rickard, C., M., 2015. Complications of central venous access devices: a systematic review. Pediatrics 136 (5), e1331-1344.
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Webster, J., Larsen, E., Marsh, N., Choudhury, A., Harris, P., Rickard, C.M., 2017. Chlorhexidine gluconate or polyhexamethylene biguanide disc dressing to reduce the incidence of
central-ACCEPTED MANUSCRIPT
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line-associated bloodstream infection: a feasibility randomized controlled trial (the CLABSI trial). J Hosp Infect 96 (3), 223-228.
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a b
Figure 1: Kaplan Meier estimates of skin complications development over dwell time:
aPeripheral (venous and arterial)
bCentral
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Table 1. Participant and device characteristics: (7,669 participants and 10,859 devices)
Variable Frequency (%)
By participant
Age (years)
a(n=7,662) 59 (42-71)
Infant (<12 months) 12 (0) Paediatric (1 to 15 years) 126 (2) Adult (16 to 69 years) 5,386 (70) Elderly (70 years or older) 2,138 (28)
Diagnosis at insertion (n=7662) Surgical 5,003 (65)
Medical 1,963 (26)
Oncology / haematology 225 (3)
Other 471 (6)
Skin integrity overall (n=6864) Good 3,980 (58)
Fair 2,206 (32)
Poor 678 (10)
Skin type (Fitzpatrick scale) (n=4,014) Pale white 347 (9)
White 2,676 (67)
Light brown 582 (14)
Moderate brown 358 (9)
Dark brown / black 51 (1)
Wound at baseline (n=7,192) 1,528 (21)
BMI category (n=3,396) Normal / underweight 1,545 (45)
Overweight / obese 1,851 (55)
Comorbidities (n=7,293) None 1,556 (21)
One 1,685 (23)
Two or more 4,052 (56)
By device
Catheter type (n=10,859) Peripheral venous 9,933 (91)
Peripheral arterial 341 (3)
Peripherally inserted central catheter 317 (3)
Non-tunnelled CVAD 220 (2)
Tunnelled CVAD 48 (0)
Insertion site (n=10,847) Forearm 4,881 (45)
Hand 1,514 (14)
Antecubital 1,032 (10)
Cephalic 808 (8)
Foot 628 (6)
Wrist 430 (4)
Basilic 337 (3)
Radial 332 (3)
Internal jugular 249 (2)
Brachial 32 (0)
Subclavian 18 (0)
Other 586 (5)
Dwell time (days)
a(n=10,488) Total 2.5 (1.5-3.8)
Peripheral
b2.4 (1.5-3.6)
Central
b4.8 (2.6-10.1)
Any complication prompting device removal (n=10,487)
2,579 (25)
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Variable Frequency (%)
Frequencies and column percentages shown unless otherwise noted;
amedian and inter-quartile range;
b=peripheral venous and arterial catheters; c=peripherally inserted central catheter, non-tunnelled and tunnelled CVAD; n = number of non-missing values; BMI=body mass index; CVAD=central venous access device
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Page 21 of 25 Table 2. Dressing and securement characteristics (n=4,965)
Frequency (%)
Sutured (n=4,965) 146 (3)
Dressing type (n=4,931) Plain polyurethane 2,699 (55)
Bordered polyurethane 1,802 (37) Integrated securement dressing 236 (5)
Fabric 134 (3)
Honeycomb 60 (1)
Securement device type (n=4,965) Sutureless securement device 1,365 (27)
Tissue adhesive 852 (17)
Elasticised bandage 166 (3)
Additional plain polyurethane 109 (2)
Bandage 25 (1)
Non sterile tape 8 (0)
Additional bordered polyurethane 2 (0)
None 2,438 (49)
Dressing changes (n=2,895) Zero 2,396 (83)
One 304 (10)
Two 99 (3)
Three 47 (2)
Four or more 49 (2)
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Table 3. Vascular access associated skin complications, and signs and symptoms by device
Variable Peripheral Central Total
freq. (%) IR (95% CI) freq. (%) IR (95% CI) freq. (%) Skin complications
Any complication (n=3,928)
442 (12.3) 46.2 (42.1-50.7) 40 (11.7) 22.5 (16.5-30.6) 482 (12.3) Bruise (n=4,072) 134 (3.7) 14.0 (11.8-16.6) 33 (6.8) 10.2 (7.27-14.4) 167 (4.1) Infiltration (n=9,820) 296 (2.9) 11.0 (9.79-12.3) 1 (0.3) 0.56 (0.08-3.99) 297 (3.0) Dermatitis (n=4,653) 19 (0.5) 1.85 (1.18-2.91) 13 (2.2) 3.03 (1.76-5.21) 32 (0.7) Mechanical injury (tear)
(n=4,598)
12 (0.3) 1.17 (0.66-2.06) 10 (1.7) 2.33 (1.25-4.33) 22 (0.5) Mechanical injury (blister)
(n=4,598)
6 (0.2) 0.59 (0.26-1.30) 8 (1.4) 1.86 (0.93-3.72) 14 (0.3) Local infection (n=4,974) 9 (0.2) 0.88 (0.46-1.68) 2 (0.3) 0.47 (0.12-1.86) 11 (0.2) Skin complication signs and symptoms
Any sign or symptom (n=2,554)
356 (15.2) 57.0 (51.4-63.3) 11 (5.0) 17.0 (9.40-30.6) 367 (14.4) Leakage (n=8,723) 2,069 (24.8) 86.6 (83.0-90.4) 6 (1.5) 2.59 (1.16-5.76) 2,075 (23.8) Erythema (n=8,446) 438 (5.3) 18.5 (16.9-20.3) 7 (3.2) 10.8 (5.15-22.7) 445 (5.3)
Pain (n=10,246) 626 (6.3) 22.6 (20.9-24.5) 0 (0.0) - 626 (6.1)
Itchiness (n=3,020) 15 (0.6) 2.23 (1.40-3.85) 21 (3.6) 4.89 (3.19-7.50) 36 (1.2) Overall (n=2,128) 494 (25.9) 88.8 (81.3-97.0) 20 (9.1) 30.9 (19.9-47.8) 514 (24.2) column percentages calculated using the number of non-missing observations in the denominator; n = number of non-missing observations; IR = incidence rate per 1,000 device-days; CI = confidence interval; combined values shown as “Any” are not necessarily equal with the sum of frequencies of the components due to missing data; freq. = frequency;
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Table 4. Unadjusted Hazard Ratios: Peripheral venous and arterial catheters
Skin complications Signs and symptoms
Bruising Infiltrati on
Dermati tis
Mechani cal (tear)
Leakage Erythem a
Pain Itch Age (years) 1.01
(1.00,1.
02)
0.99 (0.99,1.
00)
0.99 (0.99,1.
00)
0.99 (0.98,0.
99) Diagnosis (ref.
surgical)
Medical 2.97
(2.09,4.
22)
1.95 (1.53,2.
48)
4.22 (1.70,10 .5)
0.69 (0.62,0.
77)
1.33 (1.12,1.
59)
7.70 (2.42-24.6) Not
medical/oncology/
surgical
12.4 (5.90,26 .0)
6.13 (3.23,11 .6) Skin integrity
(ref. good)
Fair 1.61
(1.26,2.
06)
0.76 (0.69,0.
84)
0.75 (0.63,0.
90)
Poor 4.12
(2.66,6.
39)
1.98 (1.39,2.
84)
48.4 (5.94,>1 00)
0.69 (0.58,0.
82)
0.58 (0.41,0.
82)
Wound at
baseline
3.71 (2.63,5.
22)
5.62 (4.47,7.
06)
3.58 (1.44,8.
91)
0.17 (0.13,0.
21)
1.53 (1.27,1.
84) Comorbidities
(ref. none)
One 3.40
(1.62,7.
14) Two or more 3.74
(1.89,7.
41)
>100 (>100,>
100) Arterial catheter
(ref. venous)
16.0 (3.30,77 .4)
0.13 (0.04,0.
40) Insertion site
(ref. forearm)
Hand 0.41
(0.22,0.
77)
1.78 (1.60,1.
97)
Antecubital 1.57
(1.37,1.
79)
Cephalic 4.11
(2.58,6.
54)
4.38 (3.23,5.
95)
0.11 (0.07,0.
18)
0.38 (0.22,0.
65)
4.50 (1.47,13 .8)
Foot 3.15
(1.73,5.
72)
5.31 (3.80,7.
41)
0.04 (0.02,0.
11)
0.09 (0.02,0.
37)
1.91 (1.42,2.
57)
Wrist 0.65
(0.51,0.
84)
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Radial 18.0
(3.27,98 .6)
0.13 (0.04,0.
40)
Basilic 4.15
(1.93,8.
91)
12.4 (2.74,55 .9)
26.0 (5.04,>1 00)
0.11 (0.03,0.
43)
Other 6.17
(3.87,9.
83)
3.32 (2.25,4.
90)
0.27 (0.19,0.
39)
0.17 (0.06,0.
46)
1.80 (1.34,2.
43) Securement (ref.
none)
Tissue adhesive 6.92
(2.08,23 .0) Unadjusted (univariable, or crude) statistically significant (p<0.01) Hazard Ratios (and 95% confidence intervals) shown; blank = non-significant at p≥0.01; complications and abnormalities with no statistically significant associations are not shown;
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Table 5. Unadjusted Hazard Ratios: Central venous access devices Bruising Dermatitis Mechanical
(tear)
Mechanical (blister)
Age (years) 1.02 (1.01,
1.04) Diagnosis (ref. surgical)
Medical >100 (>100,
>100) Wound at baseline 3.67 (1.77,
7.63) Comorbidities (ref. none)
One >100 (>100,
>100)
Two or more $
Securement (ref. none) Sutureless securement device
0.28 (0.11, 0.68)
Tissue adhesive >100 (>100,
>100)
Unadjusted (univariable, or crude) statistically significant (p<0.01) Hazard Ratios (and 95%
confidence intervals) shown; blank = non-significant at p≥0.01; CVAD= Central venous access device; complications and abnormalities with no statistically significant associations are not shown; $ = cannot be calculated;
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Telephone triage in midwifery practice: A cross-sectional survey
Carolyn M. Bailey
a,c,*, Jennifer M. Newton
a,d, Helen G. Hall
baNursingandMidwifery,FacultyofMedicine,NursingandHealthSciences,ClaytonCampus,MonashUniversity,WellingtonRd,Clayton,VIC,3800,Australia
bNursingandMidwifery,FacultyofMedicine,NursingandHealthSciences,PeninsulaCampus,MonashUniversity,McMahonsRd,Frankston,VIC,3199, Australia
cSchoolofNursing,Midwifery,andHealthcare,FacultyofHealth,GippslandCampus,FederationUniversityAustralia,NorthwaysRoad,Churchill,VIC,3842, Australia
dSchoolofNursing,McMasterUniversity,Hamilton,Ontario,Canada
ARTICLE INFO
Articlehistory:
Received21March2018
Receivedinrevisedform7August2018 Accepted16November2018
Keywords:
Midwives Telephonetriage Telephonepractices Triageskills Surveydesign
ABSTRACT
Background:Childbearingwomencommonlyaccessmaternityservicesviathetelephone.Amidwife receiving thesecalls listenstothewoman’sconcerns and thentriageswomen according to their assessment.Thismayresultintheprovisionofadviceandinstructionoverthetelephoneorinvitingthe womanintothehealthserviceforfurtherassessment.Midwivesareresponsibleforallcareandadvice giventowomen,includingviathetelephone.
Objectives:Thepurposeofthisstudywastoexploretheexperiencesandpracticesofmidwivesregarding theirmanagementoftelephonetriage.
Design:Across-sectionalsurvey.
Settingandparticipants:Purposivenon-probabilisticsamplingofcurrentlypractisingmidwifemembers ofprofessionalorganisationswasusedtorecruitparticipants.Fromthis,242midwivesrespondedand 230returnedvalidsurveyswereusedindataanalysis.
Methods: Participant demographics, telephone triage processes, skills, educational preparation, confidenceandanxietylevels,andexternalfactorsthatinfluencemidwives’managementoftelephone triagewerecollectedviaanon-linesurvey.Descriptivestatisticsandfurtheranalyseswereconductedto explorerelationshipsbetweenvariables.
Results:Eighty-threepercentofmidwivesrespondto2–5telephonecallspershift,withonly11.7%
(n=24)ofmidwivesreportingthatthisisincludedintheirworkloads.Telephonetriageisfrequently managedinenvironmentswithdistractions.Mostmidwives(84%;n=177)reportreceivingnotrainingin thisskill.Confidenceinperformingtelephonetriagewasreported,withhigherconfidencelevelsrelated tomidwives’increasedyearsofexperience(p<0.05)andage(p< 0.01).Anxietyrelatedtomanaging telephonetriagehasbeenexperiencedby73%(n=151)ofmidwives,withthisbeinggreaterinmidwives withlessyearsofexperience.Anxietyisreportedlessbymidwivesinruralorremotesettingscompared tometropolitanorregional(p<0.05)settingsinthisstudy.Avarietyofstandardsandaidstoguide practice,anddocumentcallsareutilisedinarangeofways.
Conclusion: To the authors’ knowledge, this is the first study conducted to explore midwives’
practisesintelephonetriage.Thefindingssuggesttheneedforappropriateenvironmentstoconduct telephonecallsandtheinclusionoftelephonetriageinmidwiferyworkloads.Inaddition,consistent educationandprocessesarerequiredtoreduceanxietyandsupportmidwivesprovisionofthisservice towomen.
©2019ElsevierLtd.Allrightsreserved.
*Correspondingauthorat:NursingandMidwifery,FacultyofMedicine,NursingandHealthSciences,ClaytonCampus,MonashUniversity,WellingtonRd,Clayton,VIC, 3800,Australia.
E-mailaddress:[email protected](C.M. Bailey).
https://doi.org/10.1016/j.ijnurstu.2018.11.009 0020-7489/©2019ElsevierLtd.Allrightsreserved.
ContentslistsavailableatScienceDirect
International Journal of Nursing Studies
j o u r n a lh o m e p a g e : w w w . e l s e v i e r . c o m / i j n s
Whatisalreadyknownaboutthetopic?
Childbearingwomenusethetelephonetoaccessmidwiferycare andmaternityservicesattimesofuncertainty.
Midwivesuseinformationprovidedbychildbearingwomento determinetheirneedtoattendin-personforfurtherassessment.
Midwivesrequirestrongcommunicationskills,experienceanda soundclinicalknowledgebasetomanagetelephonetriage.
Whatthispaperadds
Midwives’ of various experience levels commonly answer at leasttwotelephonecallsfromchildbearingwomeneachday.
Mostmaternityservicesdonothaveadedicatedservicenorhave midwivesreceivedspecifictraining.
Astandardisedandcoordinatedapproachtotelephonetriageis requiredformidwivestoprovidesafe,qualitycaretowomen theyworkwith.
1.Introduction
Telephonetriageis a processusedtodeterminethelevelof urgency and type of health care required, and involves the caregiveraskingquestionstoestimateurgency,giveappropriate adviceandidentifytheneedforreferral(Huibersetal.,2011).The useofthetelephonetoaccesshealthcarehasbeendocumented sincethemiddleof thetwentieth centuryasawell-established practice,withwomenaccessingtheserviceacrossthechildbearing continuum(DeVore,1999).Thepurposeofmaternitytelephone triageisgenerallytodetermineifthewomanrequiresanin-person assessmentorreferraltoanotherservice(DeVore,1999;Janssen etal.,2006;Kennedy,2007).
Whilstthereismuchdiscussioninthenursingliteratureonthe topicoftelephonetriage,thereisapaucityofresearchfocusingon themidwiferydiscipline.Inarecentscopingreviewtheauthors foundonlyelevenpaperswrittenonthetopicoftelephonetriage and midwifery practice (Bailey et al., 2018).Authorship of the papers was dominatedby theUnitedKingdom (n= 8)and the UnitedStates (n= 3)with noothercountries identified in the searchonthistopic.Oftheincludedpapersonlyonewasprimary research, the remaining papers were either discussion, quality improvementorclinicalaudits.Theoneresearchinvestigationwas a qualitative study undertaken in the United Kingdom that explored midwives’ views of care provided to women via the telephone(Spibyetal.,2014).Thisstudywasinthecontextofearly labourcareandfoundtherewasconflictbetweenmidwives gate-keepinglabourwardandprovidingsupporttowomen.Spibyetal.
(2014)suggestthattelephonetriageshouldbeadiscreteservice independentfromlabourward.Telephonetriagerelatestonotonly early labour care as women or their partners may phone the midwifeorhealthserviceforanymatterrelatedtotheirpregnancy, labour,or early postnatal care.Thisrequiresthemidwife tobe clinicallyknowledgeableandpreparedforanypotentialproblem presentedviathetelephone.
Previous research recommends that midwives performing telephone triage need to have a sound midwifery knowledge base,beexperienced,haveexcellentcommunicationskills,highly developeddecision-makingskills,andtheabilitytoprioritiseand multi-task(Cherryetal.,2009;Clarkeetal.,2012;Mahlmeisterand Van Mullem, 2000; Nolan et al., 2007; Webb, 2004). Specific educationintheseareasisfrequentlyrecommendedasastrategy todevelopthenecessaryskillsfortelephonetriage(Cherryetal., 2009; Finlayand Brown, 2013; Mahlmeister and Van Mullem, 2000;Nolanetal.,2007).Despitetheserecommendations,there
arenopublishedresearchstudiesthathaveevaluatededucationor compared experienced and novice midwives management of telephonecalls.MidwivesinSpibyetal.’s(2014)studysuggestthat midwivesshouldalreadypossesstheseskillsandproposethereisa need for teaching midwives how to identify nuances over the telephoneinsteadofformalisedtraining.
There are potential pitfalls during telephone triage such as hurried and interrupted calls, failure to evaluate properly the callers’needsorurgencyoftheproblem,andhighlevelsofward activitynotconducivetowomancentredcallmanagement,which mayinfluencedecisionsmade(Ament,1999;Clarkeetal.,2012).
FinlayandBrown(2013)foundthatdevelopmentofaconsistent approach to telephone triage assisted in mitigating risk. This consistentapproachincludedstrategiessuchasimplementinga structuredcallprocessand standardiseddocumentation. Devel-opmentofdiscretetelephonetriageservicesinthree UKhealth facilitiesresultedinimprovedpatientflow,reductionof inappro-priate admissions, less telephone calls to other clinical areas, increasedjob satisfactionfor midwives,improvementin labour wardworkload,lessunnecessarytravelforwomen,andimproved continuityofcareforwomen(Cherryetal.,2009;Kennedy,2007;
WeaversandNash,2012).
Despite the longstanding usage of telephone triage in midwiferypracticesoverthe20thcentury(Angelini, 1999;DeVore, 1999; Kelley and Mashburn, 1990) and into the 21st century (Kennedy,2007; Webb,2004), howmidwivesenactthis role is largelyunknown(Baileyetal.,2018).Givenitisessentialworkof themidwifeandmaternityunitsgenerallyofferthisservice24ha day 7 days per week, midwives need to be able to practice independentlyinmanagingtelephonecalls.
Thispaperpresentsthefindings fromphase oneofa mixed methodsstudyusinganexplanatorysequentialdesigntoexplore howmidwivesmanagetelephonetriage(CreswellandPlanoClark, 2011).Anonlinesurveytoolwasusedtogatherawiderangeof viewsonthetopic.Theprimaryaimofthisstudywastoexplorethe experiences and practicesof midwivesin theirmanagement of telephone triage. This study addresses the following research questions: How do midwives manage telephone triage? Are midwives specifically prepared for telephone triage through education or training? Are midwives confident in telephone triage?
2.Methods
A self-administered online survey tool was developed to investigate the views, experiences and practises of midwives managing care of women during telephone triage. Despite an extensivereviewoftheliteratureinthedisciplinesofmidwifery andnursingtodetermineiftherewasavalidatedsurveytool,no tool regarding telephonetriage was identified.We developeda questionnaire from identified themes from the literature and consultation among the research team who have expertise in midwifery.Developmentofthesurveytooltookseveraliterations until consensus among the research team was reached. One researcher (CB) developed the questions and sequence of questioning, one researcher (JN) reviewedthequestions, types, sequence,and relevance,withthethird researcher(HH)editing andprovidingthefinaldecisiononareasofcontention.Thefinal survey tool consisted of forty-nine questions including scaled itemsonafive-pointLikertscale,multiple-choicequestions,closed and partially closed questions, and open-ended questions. The survey tool had three sections: the first sought participant demographics,sectiontwosoughtinformationonprocessesand preparation, whilst the third section sought information on participants’experiencesandfactorsinfluencingtelephonetriage.
ThesurveytoolissummarisedinTable1.
C.M.Baileyetal./InternationalJournalofNursingStudies91(2019)110–118 111
Apaneloftenmidwiveswithclinicaland/orresearchexpertise assessedcontentvalidity.Thepanelevaluatedindividualquestions aswellasthesurveytooloverall,usingafour-pointLikertscale measuring from not relevant to highly relevant. Each panel member’s response was evaluated to establish the extent of contentvalidityforeachitemandoverall(AyreandScally,2014;
Politetal., 2007).Afterthefirstroundofreview, one question neededre-wordingandtwoquestionswereratednotrelevantby mostpanelmembers(n=8)andwereremovedfromthesurvey tool. The panel who all agreed on face validity evaluated the revisedtool.Thisallowedforcalculationofbothindividualitems andthescalescontentvalidityindex(Politetal.,2007).Individual itemsscoredacontentvalidityindex(I-CVI)of0.80–1.0,exceeding therecommended0.78(Politetal.,2007).TheScale-levelmean ItemContentValidityIndex(S-CVI/Ave)is0.94,whichisabovethe recommended 0.90 (Ayre and Scally, 2014; Polit et al., 2007).
Followinginstitutionalethicalapprovalthesurveytoolwaspilot tested with a small sample of currently practising midwives (n=15). Thesurveytool wasuploaded totheweb-based online surveysiteQualtrics1(https://www.qualtrics.com/).Thispilottest wasparticularlyimportant.Asidefromtestingifquestionswere workingasintended,withthesurveytoolbeingweb-based,details suchasaccesstothesurveytoolfrommultipleplatforms,timeto complete the survey tool, skip instructions, and movement throughthesurveytool(forwardandback)werealsoimportant toassess(Dillmanetal.,2009).Reliabilityoftheconfidencesurvey scales(12items)usingCronbachalphawas0.942,demonstrating goodreliability(DeVaus,2014).
2.1.Participants
Purposive non-probabilisticsampling was usedtoselectthe populationunderinvestigation,namelycurrentlypractising mid-wives(Nardi,2014).Thissamplingapproachwasusedtoinvolve individualsthatareespecially knowledgeableorexperiencedin thephenomenaofinterest(CreswellandPlanoClark,2011).Based onapopulationof8528midwivesemployedinVictoria(AHPRA, 2017)withaconfidencelevelof95%andconfidenceintervalof5 thesamplesizecalculatedwas368.Twomidwiferyprofessional organisations were contacted to assist with circulation of the survey tool. The Australian Nursing and Midwifery Federation (ANMF)Victorianbranchagreedtocirculatethesurveytoolviaa linkintheire-newsletterandontheirwebsiteandsocial media pages.TheAustralianCollegeofMidwives(ACM) circulatedthe survey link in their e-newsletter. It is unknown how many midwivesregisteredinVictoriaaremembersofeitherprofessional organisation;however,thistwo-prongedapproachwastakento reachasmanymidwivesaspossible.Datacollectionoccurredfrom April to September 2017, with reminders sent throughout this period.All surveyresponses wereanonymous, withconsent to participate implied by completion of the survey tool. Survey questionswerenotcompulsory,thusparticipantshaddiscretion over what they answered. No incentive to participate was provided.
2.2.Setting
ThesettingforthisstudywasVictoria,Australia.Victoriaisthe mostdenselypopulatedoftheAustralianstatesandgeographically is approximatelythe sizeof theBritishIsles. Thepopulationis mainlyconcentratedonthecapitalcityofMelbourne.Midwives workin a varietyof practice settings includingthe publicand private hospital sector, private midwifery practice, community healthsettings,anddomiciliarycareservicesthatarelocatedin metropolitan,regionalandruralorremoteareas.Therearevarious modelsofcareincludingmidwiferyled,sharedcareandmedically led.The main publichealth service in the stateis government fundedandguidelinesforpracticeareimplementedfromacentral governancebodythathasinputfromcliniciansandconsumers.
2.3.Dataanalysis
Data were analysed using IBM SPSS Statistics for Windows, version24(IBMCorporation,2016).Dataweresummarisedusing descriptivestatistics.Forthecontinuousvariablesinthissampleof midwives,thedistributionforagewasasymmetricbimodal,and for years of experience the distribution was unimodal with skewness to the right (Welkowitz et al., 2011). As parametric statistical tests assume a normal distribution of data non-parametricstatistical testswereused (Albers,2017; Welkowitz etal.,2011).Relationshipsandcomparisonsamongvariableswere exploredusingChi-square,Mann-WhitneyUandKruskal-WallisH tests.
3.Results
Twohundredandforty-twomidwivesrespondedtothesurvey.
A criterion for inclusion in the study was for midwives to be currentlypractising.Therewere5%(n=12)ofsurveyrespondents thatwerenotcurrentlypractisingmidwiferyandwereopted-out of theremainderof thesurvey. Theremaining95% (n=230)of respondentswerecurrentlypractisingandcompletedtherestof thesurvey. Not allmidwives answeredallquestions and some questionsresultedin‘notapplicable’responses.Noattemptwas madetoimputemissingdataforanalysis.Theresultshavebeen groupedtogetherandarereportedunderthefollowingthemes:
Characteristicsofstudyparticipants,Respondingtotelephonecalls andmanagingworkload,Guidanceanddocumentation,Education andcompetence,andConfidenceandanxiety.
3.1.Characteristicsofstudyparticipants
Participant demographics are summarised in Table 2. All respondentswerefemalewitha minimumageof22 yearsand maximum of 68years (M=43.6, SD=12.4). Years of experience ranged from 6 months to 42 years (M=15.7, SD=11.9).Of the midwives,(82.7%;n=199)werequalifiedasbotha nurseanda midwife.Qualificationsofthissampleofmidwiveswasbyhospital certificate(29.6%;n=66),postgraduatedegree(39.5%;n=88),and Table1
Summaryofquestionsincludedinsurveytool.
Surveytool
Section1:Participantdemographics Thissectionincludedquestionssuchas:geographicallocationthemidwifeworked,thelevelofhealthcareservice, whetherpractisinginamidwiferyledmodelofcare,age,yearsofmidwiferyexperience,whereinitialqualificationwas gained,typeofqualification,primarypracticesetting,amountofcallsmanaged.
Section2:Processesandpreparation Thissectionsoughtinformationonpreparationofthemidwifefortelephonetriage,educationortraining,competence, supervisionofnovices,processesortoolsinplacetosupportthepractice,documentationused,policiesorguidelines availabletothemidwife,confidenceandanxietylevelsofmidwives.
Section3:Midwives’experiencesandfactors thataffectpractice
Thissectionsoughtinformationonthemidwives’ownexperiencesoftelephonetriage,skillsused,organisationalfactors e.g.workloads,environmentcallsaremanaged,competinginterests.