In this section we first present an overview of the Work Flow in the chat automation system. After this we present an analysis of the experiences of nurses in relation to the automation based on the job demands and job resources theory by Demerouti et al. .
The system requires patients to specify which medical problem they are seeking advice for and answer predefined questions derived for this problem before the nurses handle the case. Even though not implemented in the project, the system provides the possibility to use the initial answers to triage patients before further handling.
In Fig. 2 we illustrate the workflow for the patient and the nurse for finding advice for the medical problem. The workflow is numbered from 1 to 7, where 4a and 4b happen in parallel.
When entering, the patients log in with a national e-identification system. The patient then first answers predefined questions prior to entering the chat system. The nurses can read the answers, but are not able to read the wording of the questions that the patient answers. The nurses have to use three different systems in parallel to give advice to one patient and conclude the conversation in the chat system. The use the Internet, the RGS system which is a medical advice support system for professionals and a journal system to document the results. The nurses also do a triage of the patient, which is a process for sorting and prioritizing patients based on the problems and symptoms that the patients describe such as body temperature, heart beat and pulse. Nurses can have up to 6 or 7 patients simultaneously, each in different steps of the workflow, so a nurse could be concluding a chat with one patient, but keeping a discussion open for the other patients.
The workflow for giving advice on the phone is mostly that the patient explains the health problem verbally and the nurse asks questions to understand the problem and the severity. The nurse serves one patient at a time. When the nurse feels (s)he is ready, (s)he gives advice and concludes the conversation. The nurse uses a system to select a patient to talk to and can go online to seek information for the advice.
Generally, time pressure was not experienced as a problem in the chat. However, a few areas emerged from the interviews and are presented below.
Experience of Queue Many nurses find that the queue in the chat is stressful when there are more than 6–7 patients waiting in the chat. This is interesting since none of the interviewees found the queue stressful when working on the phone with patients. Here, the interviewees describe that the queue is a joint queue in the phone, and that it is always there, and you have a shared responsibility with many others while in the chat you do not have the same support from colleagues. During the case study, this has not been a major problem as few patients have used the service, but there is a concern that the problem would be greater if many would use the chat in the future.
“You see the patients coming in all the time and look like okay now we or I have eight waiting. Because it’s more personal. In a queue where there are lots and lots of people waiting/…/you let go.”
Not knowing how many patients are coming in Several nurses also complain that the so called Onboarding feature showing incoming patients to the chat is not a help, and that part of the systems can be improved.
“It can be said that there are four patients on the way. On boarding. And then there will be no patients. Then it can be the other way around. That it says nothing at all, but that several show up. Eeeh okay.”
Many patients in parallel Many nurses find it stressful to have many patients in parallel in the system, and that there is an absolute limit to how many you can chat with at the same time. Also, many think that there should be a limit to how quickly patients should respond.
“For me/…/it gets a little more stressful because we are expected to have several patients at the same time. And we also have to have that, if there is high pressure, to be able to keep this response time for a maximum of one hour/…/and that it is stressful because you constantly see the queue. That’s the big difference, on the phone you know the queue is almost constant.”
Emotional Work Some of the nurses described that it is less emotionally difficult to chat with patients than to talk to them on the phone, or to work in a care unit. It is easier to keep a professional distance when communicating via text and some describe that they do not become so emotionally involved in the patient’s problems.
“I think it is calmer to sit in the chat because I have time and think about word choice. I can go back and watch the text while I have the patient”
Some nurses experience that working in the chat is slower than working in the phone service, much due to the asynchronous conversation. They describe that sometimes they can conclude the advice quickly with a patient on the phone. Some nurses had a lot of focus on finalising conversations with patients, and mentioned that it could be stressful to wait for patients’ answers in the chat since patients have 12 h to answer. The conversation became more fragmented in the chat than in the phone and therefore harder to keep the focus on the particular problem and remember all the details about it.
“You send a question away and it can take everything from two seconds, if the patient is sitting at the screen or has the app open, or 2 h. Sometimes you might not get an answer for a whole day. “
Automation text support and recipient contact The chat provides support sentences that can be used in discussion steps with the patient in the chat system. Many people use the very short greeting phrase given as supporting text, but the longer phrases are rarely used by the nurses. Most people we talked to could not explain why they did not use them. Some mention that they feel impersonal, and that they would have preferred to write the lyrics themselves so they would have been more adapted to the style you choose to have in the chat. One of the nurses explains it like this:
“I enjoy not being too controlled. I use the phrase templates very seldom/…/. Because I want to be more personal than it can be/if I use them/. It can easily happen that it becomes too robot-like if you use too many phrase templates.”
Misunderstandings and chat language Some of the nurses pointed to the difference in using chat language to spoken language. And that there is a greater risk for misunderstandings since the written sentences are quite short and do not contain the nuances of a spoken language. Many also mentioned that the voice helps them understand the decease of the person and that this part is missing in the chat.
The physical environment consists of a shared office space with two people working. Each office space is equipped with two screens and a computer. The nurses do not have their own desk but chooses the one that is available when they start working. There were very few complaints about the physical environment generally in the interviews with the nurses. A few people find it really annoying to work with two screens:
“Well, I do not want to have two screens./…/. I don’t want to have two screens in front of me.”
The physicians who worked at 1177 were offered to work from home instead of being at the office. The nurses were not given this option, but all the interviewed nurses would appreciate working from home.
“I have 1 h’s travel time each morning./…/You can organize your work in a different way. Maybe if you say that you would be stand-by or something too. I know that sometimes we have had a little panic with the staff. It was some weekend [not long ago]. On this occasion we could have worked from home and it would have resolved that weekend.”
Feedback from physicians Since many physicians work from home some nurses experience that there is not a lot of feedback between the occupations, and very little collaboration. Also, the physicians work in the evenings and the nurses work both during days and in the evenings.
“I have no collaboration since I only work during day time./…/But it is different for those who work in the evenings. Then there is more contact with the physicians, but then again many physicians work from home”
Feedback from patients Moreover, there is very little feedback from patients since the only time the nurses receive feedback on the triage is when things have gone wrong and that happens very seldomly.
“Sometimes someone has interpreted the situation in the wrong way. Often it is when a patient has called several times to 1177. And talked to different nurses”
However, almost all patients expressed their gratitude when wrapping up the chats with the nurses, and there is constant feedback and gratitude from patients. However, some of the nurses feel that the reward that they receive from the patients when helping them is less prominent in the chat. They experience that the connection is more distant, and that there is less contact:
“But you get less of that: “Thank you so much for listening” in the chat”.
There were few extrinsic rewards found in the study with the nurses. One of the things mentioned as a reward is the queue and that a short queue is a reward for them. Also, there is a strong focus on the number of patients, and the nurses keep track of how many they have answered every day. This seems to be a motivation, and a reward in itself. Salary is mentioned as a reward by one nurse only, and this person says that the salary at this work place generally is higher than in hospital care. It seems that these nurses have a strong intrinsic reward system connected to care and with meeting patients. One of the nurses explains it like this:
“Because what I really like is the meeting with the patients”
When the users seek help through the chat system, they are asked to fill in a set of predefined and automated questions before typing a particular question in the chat-part of the system. The number of questions can vary depending on the type of health problems the patients have. The nurse receives information on the answers that the patient gives, but does not see what the questions were that the patient answered nor how these were asked. Also nurses did not want to ask again about something the patient had already answered, because they thought that was unprofessional, and also annoying. One nurse explained:
“I would really like to have a better insight and understanding of what the patient fills in”
Another nurse explains that sometimes (s)he would need more information about why the patient has the symptoms described in the answers to the questions.
Additionally, the nurses commented that some questions the users answer are irrelevant for the nurses and they think some of the questions should not be asked. One of the nurses explained that the predefined questions are probably there for trying to receive a better focus on what the patient’s problem actually is, but sometimes the questions make it harder for the nurses to find the possible reason for the symptoms.
Other nurses commented that the wording of the questions to the patients from the automated system are sometimes misleading. For example if the patient has a rash, but the question asks if it is problematic for the patient to breathe then the problem of breathing could very well be disconnected to having a rash. In this case the nurse would have liked to see the logic behind the questions to the patients, to know why this question appeared.
Some of the nurses explained that they needed to ask more questions in the chat system than in a phone call, because they did not trust the information to the same degree in the chat system as on the phone. One of the nurses explains:
“It may not belong [in the patient’s case], while in the chat they only get the standard questions in the questionnaire and then they have answered yes to many different things, which they probably have [symptoms of] but may not at the moment or do not relate to what they are looking for help right now. So then I have to dig more into it”..
Others said they did not ask any further questions because they had to rely on the information that the patients had filled in before chatting. They have completely the opposite strategy and make an assessment based on the information provided by the patient in the forms they filled out. Many also feel that it is a difference to talk to the patient on the phone and that one can perceive further information from, for example, breathing.
“So purely from a medical perspective for the patient, I think this is that you do not hear the patient, you do not hear breathing or how affected they are and so there. Eh… it’s probably like the biggest negative I see it. “
The nurses describe that they have felt involved in the introduction of the IT systems and the new working methods. Continuous efforts have been made to collect comments and suggestions for improvement that have resulted in concrete measures. Many describe that they daily evaluate the work processes, and write a short report. Workshops have also been organized with the IT supplier around the systems. This increases the feeling of control in the work situation.
Many were very positive about the digitalisation of their work situation. The nurses describe that they want to participate in and influence the digital change in primary care, and that it motivates them to work for 1177 during the pilot project.
“So I see this as a chance to partly create a healthcare that feels resource efficient and secure, but also that I eventually get to choose what my working day will look like and inevitably these digital tools will come, then I can be just as happy to have the chance to develop them as well.”
There is however some criticism in the participation in the design process, and the nurses explain that the forms and the automation is based on feedback from physicians only and supports the diagnosis of patients—which is something that nurses do not do. Neither nurses, nor patients were actively involved in the design of the system:
“The chat automation templates/the forms/have been developed from the physicians perspective. That means that there are very many diagnoses there/…/. And that is a clash both for us as nurses and for the patients”
Many nurses experience very good job security at this workplace, and despite the fact that automation will replace some of the nurses’ work in 1177 there is no one that mentions this in the interviews. Some nurses are very sure of the opposite:
“Well, a robot will never take our work”
They base their feeling of job security on the many errors they see in the automation where patients answer questions about their health.
“No, a robot cannot replace us. And it is the same things as with those forms that the patients fill in. Well, 1 day all patients had palpitation. And I don’t understand that. Why do you have that when you have a rash on your hands?”
Generally in Sweden there is a large lack of nurses, and many of the nurses in the study have worked at the workplace for many years. However, the work environment in nursing has also led to the fact that many burn out or suffer from stress related symptoms such as problems with sleep in traditional nursing occupations. Several of the employees in the chat describe that the work in the chat is an new kind of nursing work, more suitable when you have had stress symptoms:
“Yes, I have been on sick leave and while I was on sick leave with fatigue syndrome I thought I would never work as a nurse again. Eh… I did not fit in the/traditional/work in hospital wards/…/. That’s why I left that and came to this/place/.
Generally, all nurses describe that they have had good supervisors’ support during the introduction of the system. This has included formal education in the system, time to practice in the system and well functioning procedures if something should go wrong with the system. Many mention that they would contact their supervisor if things went wrong in the system:
“Well. I would call the people responsible”
During the interviews it became clear that more inexperienced nurses used decision support to a very large extent and think it works very well as support in both diagnosis and triaging. Those who are more experienced do not have the same need for help. It also became clear that 1177 has good collective learning and that the nurses get good support from each other.
“I fully trust that those who have made the support have thought about and—have—checked on the situation.”
Nurses also describe how the work with the decision support is perceived as scaffolding their development.
“I’ve learned a lot. All of a sudden I feel like I have become very broad [in my medical knowledge]and suddenly I can answer as well as the neighbors’ questions about bones and everything possible”