Barriers and facilitators influencing call center nurses' decision support for callers facing values-sensitive decisions: A mixed methods study

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. Aims: 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 and Implications: 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.