Knowledge, technology and nursing: The case of NHS Direct

Abstract

NHS Direct is a relatively new, nurse-based, 24-hour health advice line run as part of the UK's National Health Service (NHS). The service delivers health advice remotely via the telephone. A central aspect of the service is the attempt to provide a standard level of health advice regardless of time, space or the background of the nurse. At the heart of this attempt is an innovative health software called CLINICAL ASSESSMENT SYSTEM (CAS). Using a number of qualitative methods, this article highlights how the interaction between the nursing staff and this technology is key to the service. The technology is based on management's attempt to standardize and control the caller-nurse relationship. Thus the software can be seen as part of an abstract rationality, whereas how it is deployed by nurses is based on a practical rationality that places practice and experience first and sees the technology and protocols as tools.

The work, workforce, technology and organisational implications of the ‘111’ single point of access telephone number for urgent (non-emergency) care: a mixed-methods case study

“…Berg 45 suggests that it is often necessary to adapt the formal rules (algorithms) of CDSS to accommodate the complex, multifaceted issues that arise in clinical decision-making, reflected in the literature about nurses using CDSS. 44,46 Flexible, non-standardised use of the system is a means of mediating the (real or perceived) 'oversensitivity' of the CDSS (or 'risk averseness' as sometimes described by staff). Previous research suggests that the CDSS is often oversensitive (it does not miss sick patients and therefore it is safe) but that it tends to 'over-triage' (it identifies 'too many' false positives because it is not specific enough).…”

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review

“…The CDSS currently used throughout NHS Direct does not have 'nurse consultation' as option, instead having the following options: A&E, immediate or routine contact with a GP, advice on self-care at home, and information giving. 28 Creation of complex protocols such as those used for triage requires a prioritisation of certain performance measures above others; while the aim of the protocols used in the control arm of the trial may be to reduce unnecessary GP appointments, the software used by NHS Direct nurses seeks to minimise malpractice risks. 28 The results of these studies suggest that it is first necessary to adequately evaluate the protocol before development of a CDSS even begins.…”

“…28 Creation of complex protocols such as those used for triage requires a prioritisation of certain performance measures above others; while the aim of the protocols used in the control arm of the trial may be to reduce unnecessary GP appointments, the software used by NHS Direct nurses seeks to minimise malpractice risks. 28 The results of these studies suggest that it is first necessary to adequately evaluate the protocol before development of a CDSS even begins. Then the CDSS should be evaluated against its paper-based counterpart, 27 following the phases outlined in the MRC framework for evaluation of complex interventions.…”

“…If adherence is greater in one arm of the trial, reasons for this can then be explored; collection of qualitative data could be useful for this, as demonstrated by qualitative studies of CDSS use in first contact care. 28,29 As discussed above, contamination is a significant issue facing RCTs in this area as inadvertent application of the intervention, or aspects of the intervention, to the control group can dilute the effects of the intervention. Therefore, randomisation should be at the practitioner or unit level.…”

Telecaretechnologies and self-management of chronic patients

“…Other ICT systems introduced in health-care for diagnosing diseases or health advice, such as the system used at the medical call center of the National Health Service (NHS) in the UK, show a similar preference for electronic triage systems based on multiplechoice questions (Hanlon et al, 2005), which reflects a reliance on abstract knowledge. However, as Hanlon et al (2005) and Oudshoorn (2011) have argued, this prioritization of abstract knowledge is problematic because health-care professionals often rely on their own experience and tacit knowledge. In order to provide good care they prefer their practical knowledge and develop "workarounds" while using the ICT systems because they don't want to fly blind on the abstract knowledge provided by the system (Oudshoorn, 2011, p. 106-107).…”