METHODS

During June 2000 we approached the 17 NHS Direct call centres then in operation in England. In 15 centres, with the help of a local coordinator who provided a list of employed nurses, we sent a four page postal questionnaire to each NHS Direct nurse who had been in post for at least one month. In the remaining two centres, a list of nurses was not provided and the questionnaire was handed out to nurses by centre managers. Nurses who had not responded after two weeks were reminded by the local coordinator. A second questionnaire was sent to non-respondents after four weeks. The questionnaire was developed after face to face meetings with NHS Direct nurses and modified in the light of two pilot studies.

RESULTS

Response rate

In all, 981 nurses were employed by NHS Direct call centres at the time of the survey, ranging from 27 to 101 at each centre. Of those able to reply, 74% (682 of 920) returned a completed questionnaire. In all, 6% (61 of 981) of nurses were unable to return a questionnaire during the survey period: 4% (38 of 981) had left the service, 1% (11 of 981) were on sick leave and 1% (9 of 981) were on maternity leave. The response rate by centre ranged from 75% to 92%, apart from the two in which the questionnaire was handed out by centre managers: in these the response rates were 46% and 61%.

NHS Direct Nursing workforce

Ninety one per cent (606 of 663) of the nurses who replied were female. Ninety four per cent (630 of 673) described themselves as white, 3% as Asian (22 of 673), and 2% (14 of 673) as black. The mean age of respondents was 40 years, ranging from 25 to 64 years, with two thirds (420 of 626) aged between 30 and 44 years. The average duration of nursing experience was 17 years, ranging from 4 to 43 years, with 84% (552 of 656) having 10 or more years experience. The nurses had a diverse range of professional qualifications in addition to their basic nursing qualification, and one fifth were also educated to degree level or above (table 1).

Most recent employment

In the three months immediately before joining NHS Direct, 20% (134 of 682, 95% confidence intervals 17% to 23%) of respondents had not been working in the NHS. Fifteen per cent (103 of 682) had been working solely outside the NHS, either abroad or in private hospital settings, or in non-nursing roles and 5% (31 of 682) had not been in paid employment (table 2). Table 3 shows the main reason given, in an open-ended question, for leaving the previous job and moving to NHS Direct. Of the 540 nurses who came from NHS nursing posts, one fifth had come from an accident and emergency department or minor injury unit (110 of 540) and one in seven from practice nursing (75 of 540). Sites differed markedly in their recruitment sources: for example, in one site 40% (17) nurses had come from accident and emergency posts, while in another only 5% (1) had done so. Despite this, recruitment sources were widely spread: of the 81 accident and emergency departments or minor injury units which supplied nurses to NHS Direct, 64 supplied only a single nurse, 10 supplied two nurses, five supplied three nurses, one supplied four, and one supplied seven.

Nurses with a disability or injury

One in ten (65 of 681, 95% confidence intervals 7% to 12%) nurses said that illness, injury, or disability had been an important reason for deciding to join NHS Direct, and a further 6% (41 of 681) that it had been a minor reason. Almost one in five (18%, 130 of 682, 95% confidence intervals 16 to 22%) of respondents considered themselves to have a disability, a work related injury or other injury or illness, of whom two fifths (42%, 54 of 130) had a back or neck problem that had caused difficulty in lifting and moving patients. Five per cent of respondents (35 of 682) said that their condition had made it difficult to work in direct patient care and 3% (20 of 682) had had to leave their job.

Working for NHS Direct

At the time of the survey, when four of the 17 centres surveyed had only been in operation for six months, 14% (85 of 607) of respondents had worked for NHS Direct for six months or less, 39% (235 of 607) for 7 to 12 months, and 47% (287 of 607) for over a year. Fifty six per cent (377 of 675) of nurses were full time (37.5 hours per week or more) and 44% (298/675) part time, with 19% (128 of 675) maintaining at least one other concurrent nursing job while working for NHS Direct. Most nurses (62%, 374 of 599) were employed at G grade, 30% (178 of 599) at F grade, 6% (38 of 599) at H grade, and fewer than 2% (9 of 599) at senior nurse or I grade.

Training and updating in NHS Direct

The amount of training varied considerably among nurses and call centres. The mean length of induction training was four weeks, although 2% of nurses (13 of 667) said they had had no induction training and a further 2% (16 of 667) reported 16 weeks. Seventy seven per cent (523 of 676) felt they had had sufficient training in using the computer decision support system, while 9% (60 of 676) felt they had not. Overall, 77% (403 of 525) of respondents said they had no time set aside for keeping their clinical skills up to date. Although, as noted, almost one in five nurses were also working in another nursing post apart from NHS Direct that may have provided the necessary updating, 60% (329 of 552) of those working only for NHS Direct had no time set aside for updating. Almost half of respondents (48%, 232 of 672) were worried about losing their clinical skills.

Clinical experience and decision support

At the time of this survey, three distinct computer decision support systems were in use by NHS Direct. Overall, 82% (553 of 675) of nurses found their centre's software easy to use, though 4% (25 of 674) felt it was “always” slow to use, and a further 82% (551 of 674) that it was “often” or “sometimes” slow to use. Almost all nurses found the decision support system helpful in triaging calls: 19% (130 of 675) felt it “always” helped in giving advice, and 80% (541 of 675) that it “often” or “sometimes” helped. However, 39% (266 of 674) noted that there were “always” or “often” problems that the system could not handle. Not surprisingly, therefore, 38% (258 of 674) of nurses said that they “always” relied on their clinical experience in dealing with calls, and a further 61% (413 of 674) “often” or “sometimes” did so. This did not differ by length of nursing experience or type of software.

Job satisfaction

Almost all nurses (95%, 642 of 676) agreed that NHS Direct offered a worthwhile service, though 1% (7 of 676) felt it did not, and 64% (433 of 674) felt their NHS Direct post was good for their career. Excluding those previously unemployed, 62% (404 of 649) felt their job satisfaction and work environment had improved, but 22% (141 of 649) felt their job satisfaction and environment had worsened since joining NHS Direct. About half of nurses (48%, 323 of 675) were rarely or never bored during their NHS Direct shift, but 16% (105 of 675) said they were always or often bored. Fifty six per cent (380 of 678) said they would like to work for NHS Direct for as long as possible. One per cent (10 of 682) of respondents noted that they had conditions that had developed since they joined NHS Direct, including repetitive strain injury, cervical spondylosis, and difficulty sitting at a computer for long.

DISCUSSION

The characteristics of NHS Direct nurses, in terms of age, gender, and ethnicity, were broadly similar to those of qualified nurses as a whole,⁸ though a smaller proportion of the NHS Direct nurse workforce was under 25 or over 50, compared with all registered nurses.⁹ One fifth of NHS Direct nurses had not come directly from other NHS employment. The proportion coming from private sector jobs was similar to the proportion of qualified nurses working in the private sector.⁸ For more than one sixth of nurses, an injury or disability had been a factor in their decision to work for the service, suggesting that NHS Direct may be having some success in “bringing nurses back” to NHS nursing. Our findings on nurse background are comparable with official figures.¹⁰ The introduction of any new health service can clearly have an impact on other services in two distinct ways: firstly, by altering the pattern of patient demand for existing services; and secondly, if it competes for the same resources, by affecting the ability of existing services to supply care. In this sense NHS Direct may carry an opportunity cost for the NHS, and in particular for alternative uses of the same staff. While the NHS Direct nurse workforce currently constitutes a small proportion (about 0.5%) of all qualified nurses in the NHS, the loss of nurses falls more heavily in some specialties, such as accident and emergency nursing and practice nursing, than in others, and the impact will vary from place to place according to local recruitment practice and the available supply of skilled and experienced nurses. Overall, our results suggest that fewer than 100 whole time equivalent nurses employed by NHS Direct in England have come from accident and emergency departments or minor injury units, which is roughly equivalent to 0.4 whole time equivalents per accident and emergency department in England. As NHS Direct may also have reduced the need for accident and emergency departments to offer telephone advice,^11,12 the overall impact of the service on available staff time in accident and emergency has probably been, at worst, neutral. Nurse recruitment from other specialties is lower than this and the impact on any one specialty seems negligible. Of course, as NHS Direct employs more nurses this position may change.⁴ Our results suggest marked variation in the amount of training received by nurses. Although our respondents seem to be more experienced and educated to a higher level than the nursing workforce as a whole, specific training in telephone triage and advice is of central importance to the quality of the service. While there is little evidence available to date on the quality or consistency of advice,^13,14 the apparent lack of common training standards is a matter of concern since nurses are unlikely to have experience of all the problems that present to NHS Direct or all the services to which they refer. Challenging in-service training might also help to relieve the boredom reported by a substantial proportion of the nurses. NHS Direct was seen by our respondents as an opportunity to leave unsatisfactory employment, to gain an improvement in pay or conditions, to do something new and challenging, or to get back into nursing. Although many were happy working for NHS Direct, feeling that the service was worthwhile and that their job satisfaction and work environment had improved, others felt their job satisfaction and environment had worsened, found the work boring, or worried about losing clinical skills. Given this, there is a strong argument for ensuring that nursing posts in NHS Direct include elements of face to face nursing as well as telephone triage. Our survey provides a snapshot of the workforce during the early days of a rapidly developing and now national service. As call volumes to NHS Direct rise, the new NHS Clinical Assessment System is introduced and employment and training practices develop, the experience of working for NHS Direct will certainly change. In addition, the growth in nurse led services of all kinds, which tend to recruit experienced and well qualified nurses from particular specialties, may lead to a greater impact on other parts of the NHS than is currently the case. The opportunity costs of these new services in staffing terms should not be ignored by policymakers.