title: Barriers and facilitators influencing call center nurses' decision support for callers facing values-sensitive decisions: a mixed methods study.
abstract: BACKGROUND
  Call center nurses triage symptoms and provide health information. However, information alone is not adequate for people facing values-sensitive health decisions. For these decisions, effective interventions are evidence-based patient decision aids and in-person nurse coaching using a structured process. Little is known about the quality of decision support provided by call center nurses.
  
  
  OBJECTIVE
  To identify the barriers and facilitators influencing the provision of decision support by call center nurses to callers facing values-sensitive health decisions at a Canadian province-wide health call center.
  
  
  METHODS
  A mixed qualitative and quantitative descriptive study from December 2003 to January 2004 using key informant interviews (n= 4), two focus groups (n= 7), a barriers assessment survey (n= 57), and analysis of simulated patient calls (n= 38) were carried out. Triangulation of these data was conducted using a conceptual content analysis method.
  
  
  RESULTS
  Participants indicated positive attitudes toward call center nurses preparing callers facing values-sensitive decisions. Facilitators included decision support resources, nurses' ability to recognize callers having difficulty, and having a supportive organizational infrastructure. The most frequently identified barriers were (a) limited usability of patient decision aids via telephone; (b) lack of a structured process to guide nurses during these types of calls; (c) nurses' inadequate knowledge, skills, and confidence in providing values-sensitive decision support; (d) unclear program direction; (e) organizational pressure to minimize call length; and (f) low public awareness of the services.
  
  
  CONCLUSIONS
  Despite call center nurses having positive attitudes, several modifiable barriers were interfering with nurses' current approaches to supporting callers facing values-sensitive decisions. Nurses wanted educational opportunities to further develop their decision support knowledge and skills, and decision support resources that are easier to use via telephone. As well, changes to organizational policies that address identified barriers could further facilitate the provision of decision support.
authors.affiliation: University of Ottawa, School of Nursing, Ottawa, Ontario, Canada. dstacey@uottawa.ca
authors.forename: Dawn
authors.initials: D
authors.lastname: Stacey
authors.forename: Ian D
authors.initials: ID
authors.lastname: Graham
authors.forename: Annette M
authors.initials: AM
authors.lastname: O'Connor
authors.forename: Marie-Pascale
authors.initials: MP
authors.lastname: Pomey
mesh_terms: D001291:Attitude of Health Personnel; D002170:Canada; D002983:Clinical Competence; D003144:Communication Barriers; D003253:Consultants; D020000:Decision Support Systems, Clinical / Q000706:statistics & numerical data; D003661:Decision Support Techniques; D019317:Evidence-Based Medicine / Q000193:education; D019538:Health Care Surveys; D015277:Hotlines; D006801:Humans; D009726:Nurses / Q000523:psychology / Q000592:standards*; D010353:Patient Education as Topic; D011787:Quality of Health Care; D012945:Social Values; D014218:Triage