Clinical Nursing Research

Volume 16 Number 2
May 2007 119-137
© 2007 Sage Publications
Predictors of Patient 10.1177/1054773806298507
http://cnr.sagepub.com
Satisfaction With Telephone hosted at
http://online.sagepub.com

Nursing Services
Susan Randles Moscato
University of Portland, School of Nursing, Oregon
Barbara Valanis
Christina M. Gullion
Kaiser Permanente Northwest, Portland, Oregon
Christine Tanner
Oregon Health and Science University, Portland
Susan E. Shapiro
University of California–San Francisco Medical Center
Shigeko Izumi
Oregon Health and Science University, Portland

Patient satisfaction has been shown to be a factor in clinical outcomes, health

care quality, and patient follow-through. Thus, a high level of satisfaction is a
desired outcome of patient care. This article examines predictors of patient sat-
isfaction with telephone nursing services among a sample of 1,939 respon-
dents, using a conceptual model derived from the literature and preliminary
work. The study was conducted in medical offices and call centers of a large
national health maintenance organization. Calls were taped and content coded
and then matched with caller questionnaire data. In the final multivariate pre-
dictive models, patient health status; caller ratings of expectations met by the
nurse for listening, clarity, and collaboration; and nurse competence were the
strongest predictors of satisfaction. Consistent with the literature, findings sug-
gest that nurses should expand interpersonal communication skills, and sys-
tems should reduce barriers to effective listening, clarity, and collaboration
with callers.

Keywords: patient satisfaction; predictive model; telephone nursing advice

T he ability to predict what contributes to patient satisfaction with tele-

phone advice services can guide decisions on how best to organize and
support these services. The perceptions, expectations, and experiences of
callers provide valuable information about the encounter with the nurse and

119

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120 Clinical Nursing Research

about service aspects of the call. This article discusses the use of a tool
measuring caller satisfaction with telephone advice nursing and outcomes
and identifies factors that predict satisfaction.

Patient Satisfaction and the Care Experience

High ratings for patient satisfaction are considered a desired outcome of
health care (Donabedian, 1980). Satisfaction has been shown to be a factor
in patient follow through (Lipkin, 1996; Valanis et al., in press), clinical
outcomes (Dingman, Williams, Fosbinder, & Warnick, 1999; Verbeek,
Sengers, Riemens, & Haafkens, 2004), and health care quality (Cleary &
Edgman-Levitan, 1997; Coyle & Williams, 2001). Components of the care
experience identified as contributors to patient satisfaction include prior
experiences (Dale, Crouch, Patel, & Williams, 1997; Henderson, Caplan, &
Daniel, 2004; Hupcey, Clark, Hutcheson, & Thompson, 2004); individual-
ized care (Frich, 2003; Schonen, Välimäki, & Leino-Kilpi, 2005); patient-
centered communication (McCabe, 2004; Verbeek et al., 2004); respect for
patient values, perspectives, and expressed needs; coordination of care,
information, and education; physical comfort and pain relief; emotional
support to alleviate fears and anxieties; involvement of family and friends;
continuity during transition out of the hospital; and access to care
(American Hospital Association and Picker Institute, 1997).
Each patient judges his or her level of satisfaction based on an individual
framework for interpreting the experience (Coyle & Williams, 2001).
Satisfaction compares a patient’s perceptions of received service quality and
the standards the patient holds for service quality (Aharony & Strasser, 1993),
that is, the relationship between “care expected and care received” (Schonen
et al., 2005). These standards may represent what is ideally expected, what
patients believe they deserve to receive, what they believe is minimally
acceptable, or expectations based on what they received in prior encounters.
Patient factors that may influence the patient’s perceptions include age, health
status, socioeconomic status, and relationship with the provider.
Rosenthal and Shannon (1997) found a clear association between objec-
tive measures of quality of medical care and patients’ subjective assess-
ment. Increasingly there is recognition that patient reports about selected
aspects of health care can provide critical information about quality not
available from medical records and expert reports (Aharony & Strasser,
1993; American Hospital Association & Picker Institute, 1997; Morgan,
1999; Vickery & Lynch, 1997). Recently, the Institute of Medicine
endorsed the use of patient perspectives to redesign patient-centered care to

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 Moscato et al. / Telephone Nursing Services 121

ensure that clinical decisions respect a patient’s needs and preferences

(Committee on Quality of Health Care in America [CQHCA], 2001).
Understanding patient perspectives can be challenging. Satisfaction mea-
sures generally assess patient evaluations of services received on either a global
scale (overall satisfaction) or specific service-related items (e.g., wait time).
Questions on the service level often are based on health professionals’ interest
in quality improvement or cost-effectiveness rather than on patient priorities
(Henderson et al., 2004; Morgan, 1999). Studies of patient satisfaction with
care generally have not examined aspects of patient–caregiver interaction.
Our Telephone ADVICE Project (Valanis, Tanner, et al., 2003) identified
aspects of nurse behavior in the nurse–caller interaction that are potentially
important caller expectations and likely to be related to caller satisfaction.
These include expressions of care and concern, responsiveness to callers’
concerns, the nurse’s competence, and individualization of care (Moscato
et al., 2003). Patients who believe their nurse and/or provider knows them
as individuals and who feel cared about are more likely to be satisfied with
care (Swanson, 1993; Verbeek et al., 2004). Another expectation of the
nurse–caller relationship is engagement in collaborative decision making.
Patients want to be informed about alternatives and be involved in treatment
decisions when more than one treatment alternative exists (Guadagnoli,
1998). Patients who take an active role in choosing and administering their
own care reportedly do better with respect to satisfaction, quality of life,
adherence to medical regime, and medical outcomes (CQHCA, 2001;
Lipkin, 1996; Verbeek et al., 2004).
Reassurance seems to be as important as the advice given (Poole,
Schmitt, Carruth, Peterson-Smith, & Slusarski, 1993), and it appears that
callers are reassured only if they believe that the professional providing the
advice is knowledgeable and considers their individual concerns. Thus,
patient confidence building is another important expectation of the
nurse–caller interaction. Finally, clarity of communication is an important
expectation. Clear communication is important legally and for patient sat-
isfaction. When advice is given to a caller, the nurse has assumed a duty,
has a legal obligation to the caller, and is responsible for any advice given
(Dunn, 1985; Tennenhouse, 1991).

Purpose

The Telephone Nursing ADVICE Project explored the relationships

between outcomes of telephone nursing advice and characteristics of

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122 Clinical Nursing Research

callers, nurses, and systems in which the advice service operates. This arti-
cle focuses on the predictors of patient satisfaction with telephone nursing
services in the ADVICE study. The nurse–caller interaction is hypothesized
to be the most important process variable predicting the outcomes of tele-
phone nursing advice (Valanis, Tanner, et al., 2003).

Method

Setting
Kaiser Permanente (KP) is a large not-for-profit health maintenance
organization with more than eight million members. The current study was
conducted in four KP regions: Southern California, Northwest, Mid-
Atlantic, and Hawaii. The four regions were selected to represent regionally
centralized call centers and decentralized medical offices that vary in the
organization and delivery of telephone advice services. The call centers and
medical offices within each region were purposefully selected to represent
variety in the characteristics of the nurses, patients, callers, and environ-
ment in which the advice services operated. The current study was
approved by the appropriate administrative committees and the Institutional
Review Board in each region. Informed consent was obtained from the
advice nurses and their callers.

Sampling and Data Collection

The current study used a nested sampling design—patients were nested
within nurses, nurses within sites, and sites within regions. This design
allowed us to link the call process and content to each caller’s perceptions
of his or her experience and learn what the caller did after the call.
Telephone advice nurses in each selected region were asked to complete
a Nurse Questionnaire (NQ) that elicited their demographic and profes-
sional background. From the nurses who completed the NQ and consented
to have calls taped, we selected 12 nurses to sample from each region (gen-
erally six from the regional call center and six from medical offices) based
on their work experience and working hours, with the goal to obtain a range
of nursing expertise and time of day.
Each of the selected and consenting nurses tape-recorded up to 150 of
their phone conversations with advice callers during a 2-week period. Nurses
obtained patient consent after reading a consent statement at the beginning of

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 Moscato et al. / Telephone Nursing Services 123

the call; if the patient refused, the call was not taped. Nurses logged identify-
ing information about each consented call, creating a Call Log. We mailed a
Caller Questionnaire (CQ) to each eligible caller to obtain their perception of
the quality and outcomes of the advice call, following up with telephone
interviews with callers who did not return the questionnaire. Follow-up
included postcard reminders and five call attempts at different times of the
day and evening during the week and on the weekend. We excluded a caller
when the nurse failed to seek consent, the recorded call was unintelligible, or
mailing a questionnaire to the home might put the caller at risk, such as a
caller who was a victim of domestic violence.

Instruments
The Call Log completed at the time of the call captured the date, time,
nurse, region, study site of the call, and caller ID. Trained coders listened
to the tape of every eligible call and coded descriptive aspects of the call
using a 50-item Call Description (CD) form and an Interpersonal
Communication Style Index (ICSI) scale for characterizing the nurse–caller
interaction. The CQ asked about the caller’s personal characteristics and the
quality and outcomes of the advice call. The NQ captured nurse character-
istics and the nurse’s assessment of the work environment. The develop-
mental and psychometric work on these investigator-developed data
collection instruments is described elsewhere (Moscato et al., 2003;
Shapiro et al., 2004; Tanner et al., 2003; Valanis, Moscato, et al., 2003;
Valanis, Tanner, et al., 2003).

Measures of Interest

Satisfaction. The measure of satisfaction is the response to the question

on the CQ: “Overall, please rate your level of satisfaction with this call,”
with five anchored choices ranging from 5 (very high) to 1 (very low).
Because of limited numbers of responses in some categories, these were
rescored to obtain a binary outcome, with a positive score (1) indicating
high to very high satisfaction and a negative response (0) indicating mod-
erate, low, or very low satisfaction.

Expectations. Using responses to items on the CQ regarding caller expec-

tations of the nurse and the extent to which these expectations were met, we
derived the Expectations Met Score (EMS) to assess caller perceptions

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124 Clinical Nursing Research

specific to nurse communication behavior during the call. The six nurse
behaviors assessed are caring, listening, clarity, knowing the patient’s med-
ical history, collaboration, and competence. For each behavior, callers rated
how important it was to them that these behaviors be present, using a four-
point scale from 1 (not very important or not applicable) to 4 (extremely
important). Subsequently the callers rated the extent to which the nurse
exhibited each of these behaviors, from 1 (not at all or not applicable) to 4
(a great deal). If the rating of the nurse’s behavior was equal to or higher
than the expectation, we scored the expectation as met 1; otherwise, it was
scored 0. Summing across these six binary scores produced a total EMS,
with a range of 0 to 6.

Other predictors. The research team selected variables from our con-
ceptual model (Valanis, Tanner, et al., 2003) that would logically relate to
the satisfaction outcome. Variables from six categories were selected:
demographics, system characteristics, caller utilization variables, expecta-
tion variables, call characteristics, and caller perceptions of call disposition
versus actual disposition of the call.

Data Analysis Procedures

To reduce the number of variables entered into our models, we selected
those variables that differed (p < .10) between satisfied and dissatisfied
callers in bivariate analyses. Due to sample size constraints and the large
number of potential predictor variables, we also divided the candidate pre-
dictors into two subset models analyzed separately—factors independent of
the call and factors dependent on the call. Nonsignificant predictors were
stepped out to simplify the model. Variables that were significant in these
two separate models were combined in a single model, again with back-
ward stepwise deletion. Nurse, region, and site were included in all models
because of the nested structure of the sampling design. Statistical signifi-
cance was set at p = .05.
To evaluate the association of predictor variables with satisfaction, we
used a repeated-measures mixed model (SAS GLIMMIX macro, Release
8.2), with callers nested within nurses and nurses nested within regions,
with the binary outcome in logit form and log link function, and a com-
pound symmetry covariance matrix within nurses. This procedure was cho-
sen because it can deal with the nested study design and the bivariate
dependent variable (Schabenberger, 2005).

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 Moscato et al. / Telephone Nursing Services 125

Results

Sample Definition
We mailed questionnaires to callers from 5,611 of the 6,012 recorded
calls and obtained 2,519 completed questionnaires (45%). For patients for
whom we had a completed CQ, we had a complete matched set of data
(coded CD, a CQ that matched the CD on ID number, and birth date) for
1,965 callers. Of these, 26 failed to respond to the CQ satisfaction question,
leaving 1,939 for the analysis reported here.

Characteristics of the Callers

The demographic characteristics of the sample used for the caller satis-
faction analysis are shown in Table 1. Because many callers indicated
mixed ethnicity and did not report specifics, we were not able to code race.
Most of the callers (84%) were younger than age 60 years, and 62%
reported themselves to be in very good or excellent health. The educational
status was high, with 65% having at least some college education. Slightly
less than one half of the sample (46%) was classified as frequent callers,
defined as five or more calls in a year. Although the importance of seeing
their own primary care provider (PCP) was rated as important or very
important by 79% of the callers, only about one half (49.5%) saw their own
PCP for more than 50% of their visits. Eighty-five percent of callers indi-
cated they were very highly to highly satisfied with the call.

Characteristics of Calls
Table 1 shows that two thirds of the calls were to the call centers and the
rest to medical offices. Calls were predominately for self-care advice
(37.5%) or about a new symptom (27%). More calls occurred on weekdays
within traditional working hours than after hours or on weekends, and most
of the callers waited 5 mins or fewer to speak to a nurse. That most calls
(85.5%) were rated by expert coders as requiring nursing management indi-
cates that callers were using advice services appropriately. The level of care
advised, compared with what callers would have done without advice,
shows that 61.3% of callers were advised care lower than what the callers
would have used without advice, whereas 33% of callers were advised a
higher level of care.

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126 Clinical Nursing Research

Table 1
Demographic, Service Utilization, and Call-Related Characteristics
of Study Sample
Characteristics of Study Sample (N = 1,939) Missing Distribution

Age in years 0
19 years or younger 39.1%
20–59 years 44.5%
60+ years 16.4%
Health status of patient 19
Poor to fair 13.3%
Good 24.8%
Very good 34.4%
Excellent 27.6%
Caller’s education 137
Less than high school graduation 8.5%
High school graduate 26.6%
Some college or technical school 31.7%
College graduate 33.2%
Frequency of calling the advice service 191
Infrequent caller (four or fewer calls/year) 53.7%
Frequent caller (five+ calls/year) 46.3%
Reported importance of seeing own 83
primary care provider (PCP)
Not very important 7.5%
Somewhat important 13.6%
Important 28.5%
Extremely important 50.4%
Percentage of visits saw own PCP 125
in last year
≤ 25% 35.8%
26–50% 14.7%
51–75% 16.0%
76–100% 33.5%
Site to which call was placed 0
Call center 67.2%
Medical office 32.8%
Region 0
Northwest 32.8%
Southern California 16.9%
Mid-Atlantic 29.7%
Hawaii 20.6%
Reason for calling 4
Self-care advice 37.5%
New symptom 26.8%
Appointment 14.2%

(continued)

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 Moscato et al. / Telephone Nursing Services 127

Table 1 (continued)
Characteristics of Study Sample (N = 1,939) Missing Distribution

Other advice 11.4%

Other, nonadvice 10.2%
Time of call
Weekday between 8 am & 4:59 pm 0 58.2%
After hours and weekends 41.8%
Hold time until talked to nurse 0
≤ 5 mins 74.8%
6–10 mins 11.7%
11–20 mins 9.5%
21+ mins 3.9%
Call required nursing management 0
Yes 89.5%
No 10.5%
Level of care advised relative to what 229
caller would have used without advice
Lower 61.3%
Higher 33.3%
Same 5.4%
Overall satisfaction with call
Very high and high satisfaction 85%
Moderate, low, and very low satisfaction 26 15%

Expectations Met Scores

Caller expectations of the nurse in five dimensions of the advice call
encounter were met for more than 80% of the 1,908 callers who had data
for these measures: caring (89%), listening (88%), clarity (87%), collabo-
ration (84%), and competency (84%). The exception was expectations for
knowing the patient’s medical history, which were met for only 65.6% of
these callers.

Bivariate Analyses
Variables that differ (p < .10) in the bivariate comparisons between
callers who were satisfied with their call experience and those who were not
are age, patient health status, importance of seeing own PCP, reason for
call, called outside office hours, call required registered nurse (RN) man-
agement, frequency of calls, region, site, nurse, length of membership,
hold time, work environment factor 3 (system limitations), work environ-
ment factor 4 (organizational support), and all six EMS measures (caring,

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128 Clinical Nursing Research

listening, clarity, knowing medical history, collaboration, and competence).

These variables were entered into the first-level modeling described below.
We found that the sample for the medical offices in Southern California
was too small (N = 14) for the likelihood estimation to converge. Therefore,
we ran two models: Model A, with Regions 2 through 4, medical offices,
and call centers included (N = 1,632 callers); and Model B, with all four
regions, but with only call centers included (N = 1,319 callers).

Multivariate Model Testing for Factors Independent of the Call

Variables evaluated in the regression model examining factors indepen-
dent of the call included patient’s age (10-year categories), health status,
length of membership, calling frequency (frequent/infrequent), importance of
seeing own PCP, region, and (Model A only) call center nested within region.

Model A (exclude callers to advice nurses in Southern California).

Factors significant in this model (Type 3 tests) are patient age, F(1, 1429)
= 7.57, p = .006; patient’s health status, F(1, 1429) = 35.88, p < .0001;
length of membership, F(1, 1429) = 5.6154, p = .0180; and importance of
seeing own PCP, F(1, 1429) = 9.31, p =.0023. Age and length of member-
ship are positively related with satisfaction, and higher satisfaction is more
likely with better health status of the patient. Importance of seeing own
PCP is negatively related with satisfaction in this model.

Model B (exclude callers to advice nurses in medical offices). Factors

significant in this model (Type 3 tests) are patient age, F(1, 1210) = 9.81,
p = .0018; patient’s health status, F(1, 1210) = 21.99, p < .0001; length of
membership, F(1, 1210) = 7.72, p = .0055; and region, F(3, 17) = 3.61,
p = .0349. The region effect (compared to the Northwest region as the ref-
erence value) appears to be located in the significantly higher caller satis-
faction in Hawaii (p = .0056).

Multivariate Model Testing for Factors Dependent on the Call

Variables entered include hold time, the five EMSs, whether RN manage-
ment was used, whether the call was after hours, two of the work environment
factors (system limitations, organizational support), and the reason for the
call. The last is a categorical variable that compared self-care, new symptoms,
appointment, and other advice with the reference level—other nonadvice, as
well as region and (Model A only) call center nested within region.

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 Moscato et al. / Telephone Nursing Services 129

Model A (exclude callers to advice nurses in Southern California) sig-

nificant factors are hold-time category, F(1, 1545) = 4.46, p = .0349; EMS
for listening, F(1, 1545) = 7.16, p = .0076; EMS for clarity, F(1, 1545) =
14.82, p = .0001; EMS for collaboration, F(1, 1545) = 58.93, p < .0001;
EMS for competence, F(1, 1545) = 28.87, p < .0001; whether the call was
after hours, F(1, 1545) = 7.16, p = .0076; reason for calling, F(4, 108) =
4.24, p = .0032; and organizational support (nurse work environment factor
4), F(1, 22) 5.31, p = .0310.
Callers whose reason for calling was advice, new symptoms, or an
appointment were significantly more satisfied than those that called for an
“other, nonadvice reason.” Hold time was negatively associated with satis-
faction. The EMSs were all positively associated with satisfaction. After-
hours callers were more likely to be satisfied. Finally, organizational
support for the nurse was positively associated with satisfaction.
Model B (exclude callers to advice nurses in medical offices) significant
factors are hold-time category, F(1, 1256) = 4.42, p = .0358; EMS for lis-
tening, F(1, 1256) = 32.22, p < .0001; EMS for clarity, F(1, 1256) = 16.33,
p = .0001; EMS for collaboration, F(1, 1256) = 40.81, p < .0001; EMS for
competence, F(1, 1256) = 24.66, p < .0001; and whether the call was after
hours, F(1, 1256) = 7.11, p = .0078. The parameter estimates have the same
interpretation as in Model A. Note that reason for calling and organizational
support is in Model A but not in Model B.

Final Multivariate Model, Combined Independent and

Dependent Factors
Variables entered were those significant in the dependent and indepen-
dent subsets, listed in the previous two sections.
Model A (exclude callers to advice nurses in Southern California) para-
meter estimates are shown in Table 2. The significant factors are patient
health status, F(1, 1420) = 17.35, p < .0001; EMS for listening, F(1, 1420)
= 35.86, p < .0001; EMS for clarity, F(1, 1420) = 11.63, p < .0001; EMS
for collaboration, F(1, 1420) = 57.71, p < .0001; EMS for competence,
F(1, 1420) = 28.67, p < .0001; whether the call was after hours, F(1, 1420)
= 4.44, p = .0353; reason for calling, F(4,106) = 2.91, p = .0251; length
of membership, F(1, 1420) = 5.64, p = .0177; and region, F(2, 23) = 4.56,
p = .0215.
Satisfaction was higher when expectations of nurse behavior were met
and if the reason for the call was nursing advice, new symptoms, or an

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 Table 2

130
Results of Final Regression Model for Model A (not including Southern California)
Effect Level Estimate SE df t Value p Value

Intercept (Northwest call center) –5.081 .600 23 –8.47 < .0001

Region (#)
(2) Mid-Atlantic .696 .333 23 2.09 .0477
(3) Hawaii .759 .374 23 2.03 .0540
(4) Northwest (reference) .000 — — — —
Call center (within Region)
Mid-Atlantic Medical office .852 .487 23 1.75 .0931
Call center (reference) .000 — — . —
Hawaii Medical office .187 .510 23 .37 .7168
Call center (reference) .000 — — — —
Northwest Medical office .662 .397 23 1.67 .1089
Call center (reference) .000 — — — —
Patient health status .411 .099 1420 4.17 < .0001
Length of membership .026 .011 1420 2.37 .0177
Reason for call
Self-care .690 .329 106 2.09 .0386
New symptom 1.140 .346 106 3.29 .0014

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Appointment .714 .373 106 1.91 .0584
Other advice .431 .393 106 1.10 .2750
Other, nonadvice (reference) .000 — — — —
Called outside office hours .638 .303 1420 2.11 .0353
Expectations met for listening 1.445 .241 1420 5.99 < .0001
Expectations met for clarity .845 .248 1420 3.41 .0007
Expectations met for collaboration 1.728 .227 1420 7.60 < .0001
Expectations met for competency 1.245 .233 1420 5.35 < .0001
 Moscato et al. / Telephone Nursing Services 131

appointment. Health status and length of membership were also positively

associated with satisfaction. Those who called the advice nurse outside of
regular office hours were more likely to be satisfied. The effect of call
center versus medical office, within region, is not significant (p = .1998).
The least squares predicted satisfaction rates by region, after adjusting for
the factors listed above, are .946 for Mid-Atlantic, .930 for Hawaii, and
.888 for Northwest. Only Mid-Atlantic is significantly different from
Northwest (p = .0477).
Model B (exclude callers to advice nurses in medical offices) parame-
ter estimates are shown in Table 3. The significant factors are patient
health status, F(1, 1247) = 11.88, p = .0006; EMS for listening, F(1, 1247)
= 31.93, p < .0001; EMS for clarity, F(1, 1247) = 17.26, p < .0001; EMS
for collaboration, F(1, 1247) = 41.18, p < .0001; EMS for competence,
F(1, 1247) = 25.13, p < .0001; and whether the call was after hours,
F(1, 1247) = 4.82, p = .0282). Model B differs from Model A in that rea-
son for calling and length of membership dropped out of the model, and
region is not significant.

Discussion

Our findings indicate that the encounter with the nurse, rather than
aspects of service structure or quality (e.g., promptness in answering the
call), is the primary reason for callers’ satisfaction with telephone nursing
advice. This is worth noting because the primary quality improvement
emphasis at the study sites was on service aspects (Valanis, Moscato, et al.,
2003). For both models, the predictors of satisfaction with the strongest
effects were the EMS for listening, clarity of communication, collabora-
tion, and competence of the nurse. Consistent with the literature, this
reflects the relationship between “care expected and care received”
(Schonen et al., 2005). Nurse competence and collaboration were the
stronger predictors. Confidence is built in the caller when there is trust that
the nurse is knowledgeable, skilled in understanding and assessing caller
concerns, and well qualified and capable of providing advice that considers
their individual concerns and fits their situation (Poole et al., 1993). The
ability to collaborate is an important indicator of nurse competence because
collaboration depends on the ability of the nurse to establish rapport with
the caller, identify the concern, assess the present condition, and work with
the caller to discuss options and select an appropriate care plan that fits the
caller’s beliefs and circumstances.

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132 Clinical Nursing Research

Table 3
Results of Final Regression Model for Model B
(not including medical offices)
Effect Estimate SE df t Value p Value

Intercept (Northwest) –4.135 .526 17 –7.86 < .0001

Region (1)
(1) Southern California .624 .419 17 1.49 .1543
(2) Mid-Atlantic .600 .339 17 1.77 .0945
(3) Hawaii .604 .382 17 1.58 .1319
(4) Northwest (reference) .000 — — — —
Patient’s health status .373 .108 1247 3.45 .0006
Called after office hours .675 .307 1247 2.20 .0282
Expectations met for listening 1.500 .266 1247 5.65 < .0001
Expectations met for clarity 1.162 .280 1247 4.15 < .0001
Expectations met for collaboration 1.590 .248 1247 6.42 < .0001
Expectations met for competency 1.286 .257 1247 5.01 < .0001

In the final model, which included call centers and medical offices, satis-
faction was higher if the reason for the call was nursing advice, new symp-
toms, or an appointment, reflecting caller expectations of what the nurse
could provide. All the predictors of satisfaction found in the current study are
consistent with results of other studies particularly that the personal experi-
ence of the current encounter influences satisfaction (Henderson et al., 2004;
Kravitz et al., 1996; Vickery & Lynch, 1997). Expectations met for listening,
clarity, and collaboration reflect patient-centered communication, individual-
ized care, and respect described by others (American Hospital Association and
Picker Institute, 1997; Schonen et al., 2005; Verbeek et al., 2004). Patient
health status, and time of and reason for the call, also are significant predic-
tors of satisfaction and reflect personal experience and the caller’s perceived
need. The positive association between health status and satisfaction sug-
gests that healthier callers may feel more confident than sicker callers that
nurses are competent to provide the information they require.
It is interesting to note that expectations met for caring was not a sig-
nificant predictive factor for satisfaction in the current study, perhaps
because this behavioral expectation has the least variation in EMS—89%
of callers said their expectation for caring was met. Qualitative data from
the comments written by respondents on the satisfaction questionnaire
showed that nurse behaviors such as careful listening (“eager to get to the
root of my problem”), collaboration (“helped me to decide”), and clarity

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 Moscato et al. / Telephone Nursing Services 133

(“talked in words I understood”) reflect caring behaviors of the nurse.

These may better describe caring than the more global behavior explored
in the questionnaire, which asked whether the nurse “shows that she or he
cares about you as a person.”

Strengths and Weaknesses

The current study was built on a conceptual model based on a literature
review and systems theory, which provides a useful way to examine the pre-
dictors of outcomes of telephone nursing advice. Findings from the current
study are consistent with other studies on patient satisfaction. The current
study developed, tested, and used new measures of the process aspects of
the calls in relation to caller expectations and caller-perceived outcomes.
The measure that resulted from relating the callers’ expectations to their
perceptions of the extent to which the nurse met these expectations pre-
dicted fairly accurately the satisfaction outcomes.
Other strengths include the large numbers of calls from four geographi-
cally diverse regions, and how the call process and content were linked to
caller perceptions of the call. The current study used multivariate predictive
models that allowed simultaneous examination of many variables related to
satisfaction, including independent and dependent factors regarding the
call, while accounting for the nesting of caller within nurse, within site, and
within region.
In compliance with human subjects requirements, we were limited to
studying only nurses who agreed to be recorded and callers who agreed to
have their call taped. Regions routinely tape calls for quality assurance
monitoring, however, so callers are accustomed to the routine phone mes-
sage that calls may be monitored for quality purposes, and few callers
refused to have their calls recorded. A review of the nurses in the current
study shows that a range of experience and expertise is represented; how-
ever, there is a potential for a sample bias if there is a difference between
the nurses who refused to participate and those who agreed to do so.
Nurses who felt less secure about their practice might have been less likely
to participate.
Another limitation was a time lag of several weeks between the call to
the advice nurse and when some callers completed the questionnaire. The
time lag may have contributed to a lower response rate and potentially less-
accurate answers. Furthermore, frequent users of advice services could
have confused the calls and reported on a different interaction than the one

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134 Clinical Nursing Research

recorded. To minimize this problem, we double-checked that caller ques-

tionnaire responses on key variables were consistent with data on those
variables from the CD form and Call Log, deleting from the sample those
without matches on these variables. In addition, caller comments on many
questionnaires indicated to us that callers remembered details of the advice
encounter and were able to state specifics about the call even though time
had passed.

Applications in Education and Clinical Practice

Patient satisfaction with telephone nursing advice depends heavily on the
caller–nurse encounter. Callers want to talk to a competent nurse who will
listen, provide clear advice, and collaborate in decision making. Strategies
that promote these nurse behaviors should be the focus of orientation, edu-
cational programs, and practice environments for advice nurses. To provide
a credible foundation for the encounter, nurses should introduce themselves
to callers as an RN. This simple step can help develop the confidence-based
association that callers expect.
A client-centered communication approach that focuses on caller con-
cerns and regularly assesses callers’ feelings and views can assist the nurse
to provide advice that is best suited to the caller. Nurses who seek callers’
views about treatment options, ask how the concern is affecting their lives,
and encourage callers to ask questions are best able to work in collabora-
tion with callers to achieve desired outcomes. For instance, a nurse in con-
versation with a caller about a new symptom who learns the caller is unable
to leave work might provide detailed information to facilitate the caller’s
judgment. Such information could include specific changes in symptoms to
watch for, the timeframe for waiting to see if self-care works, and what to
do if additional help is needed. The nurse demonstrates that the caller’s con-
cerns were heard, partners with the caller to achieve a desired outcome, and
enhances caller satisfaction.
Providing clear advice can be facilitated by using specific rather than gen-
eral terms. For instance, with a caller concerned about a new burn on his
hand, instead of saying “watch for any changes,” the nurse would say “watch
for pus, bad smell, fever, or swollen lymph nodes,” and give instruction on
what to do if these are seen. Using terms familiar to the caller can also help
clarify instructions. For example, for a sedentary television watcher needing
to strengthen his quadriceps, the nurse might suggest he do 10 quad sets
(“lock your knee 10 times”) at every commercial to get in the required exer-
cises. In all cases, the nurse should confirm that the instructions are heard and

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 Moscato et al. / Telephone Nursing Services 135

understood as intended. Having the caller repeat the instructions, ask ques-
tions, or explore other ways to meet the desired outcome are ways to assess
caller understanding and support satisfaction before ending the call.
Practices that support callers’ expectations for listening, clarity, and col-
laboration should be encouraged and rewarded by advice nurses’ supervi-
sors and supported by the health care organization. Telephone advice nurses’
performance standards thus should focus less on system and service aspects
of advice calls and more on standards that encourage these expected behav-
iors. Setting practical performance standards, measuring relevant behav-
iors, and providing periodic feedback on caller perceptions can help advice
nurses enhance patient satisfaction. Continuing education programs and
training sessions on the communication process can help nurses communi-
cate more effectively, as can cooperatively developed strategies to develop
client–provider connections.
Practice guidelines should encourage discussing causes and diagnosis
with the patient and provide descriptive common terms useful to callers.
Advice nurses should be encouraged to regularly ask patients about their
feelings and views and to involve them in the decision-making process.
Potential barriers to effective communication, such as strict time limits on
calls and strict requirements for protocol use, should be examined and
changed if they interfere with effective communication.
In the end, the onus of responsibility for patient care and satisfaction is
on the advice nurse—the quality of the caller–nurse encounter is the single
best predictor of caller satisfaction. Advice nurses should be encouraged to
develop strategies for overcoming barriers to effective listening, improve
their clarity of advice and quality of collaboration, and improve their inter-
personal communication skills. Patient satisfaction will benefit the health
care system as well as patients.

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Susan Randles Moscato, RN, EdD, is associate professor at the University of Portland School
of Nursing.

Barbara Valanis, RN, DPH, is Senior Investigator Emerita for Center for Health Research,
Kaiser Permanente Northwest.

Christina M. Gullion, PhD, is senior investigator for Center for Health Research, Kaiser
Permanente Northwest.

Christine Tanner, RN, PhD, is the Youmans-Spaulding Distinguished Professor at Oregon

Health and Science University.

Susan E. Shapiro, RN, PhD, CEN, is director of Education, Research and Clinical Practice,
UCSF Medical Center, Department of Nursing.

Shigeko Izumi, RN, PhD, is a postdoctorate fellow at the Oregon Health and Science
University.

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