Patients' Access to Telephone and E-mail Services Provided by IBD Nurses in Canada
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Journal of the Canadian Association of Gastroenterology, 2021, XX(XX), 1–8
https://doi.org/10.1093/jcag/gwab041
Original Article
Original Article
Patients’ Access to Telephone and E-mail Services Provided by
IBD Nurses in Canada
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Usha Chauhan, NP, MN, BScN, ACNP(D), CGN(C)1, , Larry Stitt, MSc2, Noelle Rohatinsky,
RN, MN, PhD, CMSN(C)3, Melanie Watson, RN (EC), MN, NP4, Barbara Currie, MN, RN-NP5,
Lisa Westin, MN, RN6, Wendy McCaw, RN7, Christine Norton, PhD MA RN8, Irina Nistor,
NP, PhD(C), MN9,
1
Hamilton Health Sciences, Hamilton, Ontario, Canada; 2Robarts Clinical Trials, London, Ontario, Canada; 3University
of Saskatchewan, Saskatoon, Saskatchewan, Canada; 4London Health Sciences Centre, London, Ontario, Canada; 5QEII
Health Sciences Centre, Halifax, Nova Scotia, Canada; 6Red Deer Regional Hospital, Red Deer, Alberta, Canada; 7Speciality
Rx, London, Ontario, Canada; 8King’s College London, London, UK; 9Queen’s University, Kingston, Ontario, Canada
Correspondence: Usha Chauhan, NP, MN, BScN, ACNP(D), CGN(C), Nurse Practitioner- Adult Digestive Diseases, Hamilton
Health Sciences, 1280 Main St. W. Room 3N51, Hamilton, Ontario L8S 4K1, Canada, e-mail: chauhanu@hhsc.ca
ABSTRACT
Background: Inflammatory bowel disease (IBD) can impact the quality of life and increase health
care resource utilization. Nurses play an integral role in ensuring ease of access to care between sched-
uled office visits.
Aims: This study aimed to capture the utilization of Canadian IBD nursing telephone and e-mail
services.
Methods: A descriptive cross-sectional study with an eight-item online survey was completed by
nurses to assess the use of nurse-led telephone and e-mail services for IBD patients.
Results: Twenty-one IBD nurses participated, and 572 patients nurse encounters were reported.
Patients with ulcerative (UC) contacted with disease flare when compared to Crohn’s disease (CD)
(40% versus 24%, P < 0.001). Nursing services were primarily utilized for queries regarding medi-
cation (39.3%), disease exacerbations (29.6%), investigations (26%), and scheduling appointments
(17.6%). Patients with CD had more telephone conversations (62.7%) and required more follow-up
telephone calls (72.2%) compared to patients with UC (33%) and 25%, respectively. Nurse-managed
interventions were provided independently for 61.4% of encounters, while 19% required a sched-
uled appointment in the IBD clinic. In the absence of telephone or e-mail assistance, older patients
were more likely to call their family doctor (r = 0.18, P < 0.001), visit the emergency room (r = 0.18,
P < 0.001), visit an urgent access clinic (r = 0.22, P < 0.001), or visit a walk-in clinic (r = 0.29,
P < 0.001) than younger patients.
Conclusions: Nurse-managed IBD advice lines are proactive services that can address most patient
disease-related concerns.
Keywords: E-mail; Inflammatory bowel disease IBD; Nursing; Patient support; Specialist nursing;
Telephone
Introduction
Canada is an ‘IBD epicentre’ (1) with one of the world’s highest negative impact on patients’ quality of life and health care uti-
prevalence rates (2). The unpredictable disease course coupled lization (2). Inflammatory bowel disease management involves
with intermittent flares and periods of remission has a substantial regular patient–provider interactions and follow-ups, focusing
Received: March 28, 2021; Accepted: October 9, 2021. 1
© Crown copyright 2021.
This Open Access article contains public sector information licensed under the Open Government Licence v3.0
(https://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/).2 Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX
on disease activity and pharmaceutical treatment approaches IBD care, while others are research nurses, case managers, and
(3,4). However, IBD patients’ care extends beyond regular biologic support program coordinators (19). The majority of
clinic follow-up due to the disease’s unpredictable nature and Canadian IBD nurses are advanced practice nurses or nurses
disease exacerbations, which do not coincide with scheduled with extensive nursing experience. Their primary role includes
appointments (2). Consequently, efforts are being made to ex- providing patient-related outpatient telephone advice, rapid
plore patient-centred ways to meet this population’s complex access to care, and transition care. Despite the variations in
needs beyond the convenience and availability of health care nursing roles, education levels, experience, and scope of prac-
providers and health services (5). tice, IBD nurses widely provide telephone advice lines (19).
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Access to gastroenterology care varies throughout Canada Telephone communication is an excellent tool in chronic dis-
(6). The management of Canadian patients living with IBD ease management and is an invaluable resource for IBD patients.
occurs in acute care locations, ambulatory clinics, and family Nurse-led telephone services provide IBD patients with a di-
practice settings (7). While clinical guidelines suggest that rect link to clinical status reports, disease and treatment educa-
patients with active IBD symptoms should be seen by a spe- tion, support, completion of health care forms, and insurance
cialist within 2 weeks (8), in practice, the wait time is typically authorization (20). In addition, nurse advice lines represent a
much longer (27% 3 to 12 months, 6% over 12 months) (9). safe and effective means of managing patients’ concerns while
Furthermore, in Canada, the number of gastroenterologists per minimizing associated health care costs (21,22). However, such
thousand IBD patients varies geographically, ranging from 1.13 nurse-led initiatives have been understudied in the Canadian
to 10.65 (10). Consequently, the lack of access to specialized population.
care places a significant strain on emergency departments’ re-
source utilization (6). STUDY OBJECTIVES
Nurse-led advice lines for IBD care are considered standard
This study aimed to capture the utilization of Canadian IBD
practice in the United Kingdom (7). While there is a recognized
nursing telephone and e-mail services for 14 days. Secondary
critical shortage of IBD nurses, 2.5 Full-Time Equivalent
objectives were to (1) compare the reasons for the telephone
(FTE) clinical nurse specialists with competencies in IBD are
and e-mail services encounters between patients with Crohn’s
recommended for a defined population of 250,000 (10,11).
disease (CD) and ulcerative colitis (UC); (2) evaluate the
Due to the increasing numbers of patients with IBD, the
IBD nurse workload associated with a telephone and e-mail
increasing complexity of the IBD nurse role, and competing
service; (3) determine the percentage of IBD patients requiring
demands on workload, the work setting can be particularly
escalated care following their encounter with the IBD nurse
stressful for IBD nurses (12). Nevertheless, IBD patients ex-
telephone and e-mail service (e.g., referral to the Emergency
press satisfaction with the care provided via advice lines and
Department, booking an outpatient clinic appointment or tests,
recommend them for their ongoing care needs (13,14). Up to
referral to allied health care providers or family doctors); and
100% of IBD nurses in the United Kingdom and 75% of IBD
(4) determine patients’ views of their preferred health care utili-
nurses in Australia provide telephone access with up to 125 in-
zation options based on age and in the absence of IBD nurse-led
coming and outgoing telephone calls per day in a high volume
telephone and e-mail services.
IBD referral centre (15).
The utilization of specialist nurses in IBD care has been as-
sociated with decreased outpatient assessments, emergency STUDY DESIGN AND METHODS
room visits, and hospitalizations, reduced hospital length of This descriptive cross-sectional study was conducted in Canada
stay, improved mental health, and greater patient satisfaction using the Canadian IBD (CANIBD) nurses’ group database.
with care (16–18). However, the role of IBD nursing is highly A total of 84 IBD nurses invited who had previously consented
dependent on government or hospital funding. In addition, to receive e-mails regarding CANIBD related initiatives were
IBD nurses are predominantly employed in academic centres, invited by e-mail to participate. A unique identifier was assigned
where large patient volumes limit nurses’ abilities to compre- to each nurse.
hensively address patients’ learning needs and concerns during An eight-item online data collection tool was developed
appointments (9). (Supplementary Appendix 1) to capture the telephone and
There are fewer than 90 IBD nurses across Canada (19), and e-mail encounters in Google Docs in English and translated
more than 270,000 individuals have IBD (8). IBD nurses in to French. Four nurses pretested this tool to ensure content
Canada have diverse roles and spend most of their time pro- validity. To enhance study participation, IBD nurses were pro-
viding outpatient care, rapid access clinics, and advice line vided with the option to complete data collection online or fax
services (14). Only 28.72% (79/275) of specialist GI nurses the completed data collection form to the principal investigator.
practicing in gastroenterology have a primary role in providing Each IBD nurse participant received the study informationJournal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX 3
and a copy of the data collection tool with instructions. The ETHICAL CONSIDERATIONS
study framework was presented to a group of IBD nurses who
Ethical approval was attained through the Hamilton Health
recommended that 2 weeks of data collection are feasible based
Sciences Research Ethics Board (HiREB Project #: 2018-
on their clinical workload. Therefore, data were collected over
2920). There was no financial incentive to participate in this
2 weeks between May 1, 2017 and June 30, 2017. The first con-
study for either IBD nurses or patient participants. Implied con-
tact with the patient participants was defined as the initial en-
sent was obtained from the nurses and verbal consent from the
counter. During the telephone encounter or via e-mail sent by
patients during the telephone and e-mail encounters. The study
the IBD nurse, patients were asked about how likely they were
was conducted following the Declaration of Helsinki.
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to utilize alternative health care services in the absence of tele-
phone or e-mail service.
RESULTS
Utilization of Telephone and E-mail Services
STATISTICAL METHODS A total of 21 nurses from 16 centres across Canada participated.
Descriptive analyses were performed for the nursing role, pa- Nurses worked with both adult and pediatric populations
tient gender, diagnosis, call length and purpose, and nursing and had varying role designations, including research nurses,
action. For each alternative health care service option that clinic nurses, Clinical Nurse Specialists (CNS), and Nurse
would have been used in the absence of the telephone or e-mail Practitioners (NP) (Figure 1). Of 572 encounters reported,
service, the percentage of those likely or very likely to use the al- there were 443 (77%) initial telephone encounters, 93
ternative was calculated by encounter type and plotted using bar (16%) initial e-mail encounters, and 36 (6%) follow-up tele-
charts. Spearman rank correlations were used to examine the phone encounters. The geographical location of the nursing
association between patient age categories and their likelihood participants included Calgary and Edmonton (Alberta),
of using alternative health care services using the Likert scale. Toronto, Hamilton, London, and Oshawa (Ontario), Sherbrook
Age was coded in increments of 5 years from 0 to >65 years old. (Quebec) and Halifax (Nova Scotia). Most of the participating
Statistical analyses were conducted with SAS Version 9.4. nurses were experienced, practicing in academic centers, while
Figure 1. Summary of nurse participants.4 Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX a minority of nurses practiced in community centers, with less In the absence of telephone or e-mail service, there were than one year experience. statistically significant associations between patient age and Reasons for the first encounter varied. Medication concerns likelihood of choosing alternative health care. Older patients were most frequent (n = 210, 39.3%), followed by disease (>46 years) were more likely to call their family doctor (r = 0.18, exacerbation (n = 158, 29.6%), investigation questions P < 0.001), visit the emergency room (r = 0.18, P < 0.001), visit (n = 139, 26.0%), scheduling appointments (n = 94, 17.6%), an urgent access clinic (r = 0.22, P < 0.001), or visit a walk-in and addressing other gastrointestinal symptoms (n = 86, clinic (r = 0.29, P < 0.001) than younger patients (
Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX 5
Table 1. Summary of the telephone and e-mail encounters
First encounter Follow-up
telephone calls after
E-mail Telephone All
e-mail (n = 36, 6%)
(n = 93, 16%) (n = 443, 77%) (n = 536, 94%)
Nurse Type
Adult 78 (83.9%) 327 (73.8%) 405 (75.6%) 26 (72.2%)
Pediatric 15 (16.1%) 116 (26.2%) 131 (24.4%) 10 (27.8%)
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Gender of patient participant
Female 45 (52.9%) 244 (57.1%) 289 (56.5%) 21 (61.8%)
Male 40 (47.1%) 183 (42.9%) 223 (43.6%) 13 (38.2%)
Age
0–18 14 (15.4%) 122 (27.6%) 136 (25.5%) 11 (30.6%)
19–45 54 (59.3%) 197 (44.6.%) 251 (47.1%) 16 (44.4%)
46–55 20 (22.0%) 95 (21.5%) 115 (21.6%) 6 (16.7%)
>65 3 (3.3%) 28 (6.3%) 31 (5.8%) 3 (8.3%)
Diagnosis
Crohn’s disease 49 (52.7%) 285 (64.8%) 334 (62.7%) 26 (72.2%)
Ulcerative colitis 36 (38.7%) 140 (31.8%) 176 (33.0%) 9 (25.0%)
Undifferentiated IBD (IBDU) 8 (8.6%) 15 (3.4%) 23 (4.3%) 1 (2.8%)
Length of Contact
30 minutes 2 (3.4%) 15 (3.4%) 17 (3.4%) 2 (5.6%)
Reason for the encounter
Disease Flare 13 (14.1%) 145 (32.8%) 158 (29.6%) 17 (47.2%)
Finances 0 (0.0%) 7 (1.6%) 7 (1.3%) 2 (5.6%)
Insurance 5 (5.4%) 16 (3.6%) 21 (3.9%) 0 (0.0%)
Investigations 16 (17.4%) 123 (27.8%) 139 (26.0%) 7 (19.4%)
Medication concerns 40 (43.5%) 170 (38.5%) 210 (39.3%) 19 (52.8%)
Other GI symptoms 10 (10.9%) 76 (17.2%) 86 (16.1%) 9 (25.0%)
Psycho-social concerns 2 (2.2%) 26 (5.9%) 28 (5.2%) 4 (11.1%)
Scheduling appointments 27 (29.4%) 67 (15.2%) 94 (17.6%) 14 (38.9%)
Non-GI symptoms 3 (3.3%) 13 (2.9%) 16 (3.0%) 3 (8.3%)
Other 10 (10.9%) 17 (3.9%) 27 (5.1%) 2 (5.6%)
Action
Referral 18 (19.4%) 95 (21.6%) 113 (21.2%) 17 (48.6%)
Contact patient support program 5 (5.4%) 37 (8.4%) 42 (7.9%) 4 (11.4%)
ER/Hospital admission 1 (1.1%) 8 (1.8%) 9 (1.7%) 3 (8.6%)
Medication adjustment 7 (7.5%) 38 (8.6%) 45 (8.4%) 3 (8.6%)
Nurse managed intervention 47 (50.5%) 280 (63.6%) 327 (61.4%) 24 (68.6%)
Schedule appointment in IBD clinic 24 (25.8%) 77 (17.5%) 101 (19.0%) 11 (31.4%)
Schedule call to reassess 7 (7.5%) 50 (11.4%) 57 (10.7%) 7 (20.0%)
Other 8 (8.6%) 32 (7.3%) 40 (7.5%) 2 (5.7%)
Canada’s vast landscape can present challenges for patients IBD-related complications (24). Advice lines provide an
living in rural areas as it can be challenging to access special- opportunity to access expert IBD nursing care and, in turn,
ized, local health care due to limited access to IBD specialists mitigate the disease burden for patients and the health care
(24). As a result, patients are more likely to utilize emer- system, particularly for rural patients. Moreover, nurse-
gency rooms require hospital admissions, and experience led IBD advice lines may decrease patients’ out-of-pocket6 Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX
Table 2. Reasons for the first encounters by diagnosis
CD UC Total P value
n (%)γ n (%)γ n (%)γ
Disease flare 80 (24.0) 70 (40.0) 150 (29.5)Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX 7
Table 3. Association between likely alternative health care utilization with age for the first encounter
Spearman’s r 95% CI P value (testing r = 0)
Call gastroenterologist office −0.11 (−0.20 to −0.02) 0.019
Call family doctor 0.18 (0.08–0.27)8 Journal of the Canadian Association of Gastroenterology, 2021, Vol. XX, No. XX
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