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A R T I C L E
The development of
telephone triage:
historical, professional
and personal
perspectives
Elizabeth Breslin and Janice Dennison
The authors examine the concept of nurse led services: professional, theoretical,
developmental, and ethical implications for the nursing profession, patients, and their
families. In the UK, the Scope of Professional Practice (1992) cleared the way for
registered nurses to expand their role, ultimately to provide a better service and to
develop the profession. The nursing profession has a strong tradition of adapting to
change and responding positively to new health care needs (DOH 1999). This nursing
strategy for England makes particular reference to nurse led initiatives and direct
reference to National Health Service (NHS) Direct; the 24-h nurse led telephone help
and advice service available across England and Wales. Particular attention will be
focused on a nurse led telephone triage which was developed in the authors own area of
elective orthopaedics. c 2002 Elsevier Science Ltd. All rights reserved.
Editors comment
Orthopaedic nurses are taking on greater and more varied roles as health care systems develop. Why and how we are
moving in this direction needs constant examination. This article discusses some of the issues relating them to
telephone triage and puts them in context.
PD
INTRODUCTION
Journal of Orthopaedic Nursing (2002) 6, 191197 2002 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S1361-3111(02)00070-5
PROFESSIONAL IMPLICATIONS
Previous to the Scope of Professional Practice
(1992), nurses had extended their role by undertaking certain tasks normally performed by
doctors. Historically nurses were trained to carry
out these extra tasks and the delegating doctor
would ensure competency was reached (DHSS
1997a,1997b). The Scope of Professional Practice
(1992) cleared the way for registered nurses to
expand their scope of practice according to a set
192
THEORETICAL IMPLICATIONS
Nurse led initiatives have always been in existence but since the 1970s have been viewed in
some areas as nursing experts caring for a
particular client group and usually with postqualication education and a research base.
Murray (1999) discussed the changing expectation of patients, carers and professional bodies.
Hancock (1997) took the view that a nurse undertaking new roles to enhance patient care
requires individuals to demonstrate their competence and accept accountability. The UK
Governments White Paper, The New NHS
Modern, Dependable (1997) and A First Class
Service: Quality in the NHS (1998) stated that
quality should be placed at the heart of healthcare. Local trusts should take responsibility for
clinical governance, ensuring that the service
being provided is quality driven and accountable.
Nursing is in a privileged position to carry this
forward as their closeness to patients provides an
avenue to promote and improve standards of
patient care. Clinical audit can be developed and
the concepts of continuing professional development can be achieved through this framework.
Nurse led services are considered to be at the
forefront of nursing development, with the
power to make clinical decisions and prescribe
programmes of care.
Dinsdale (1999) perceives the government as
being supportive of nurse led clinics because of
their impact on waiting times. It is important
that nurses who take on the advanced role do so
with the primary aim of improving the quality of
life for their patients rather that lling a void
which the reduction in junior doctors hours has
initiated (Loftus 2001). Patient and nurse contact
through the review of patients at clinics has increased and the relationship has developed.
The development of telephone triage: historical, professional and personal perspectives 193
194
telephone is a common but largely an unrecognised area of many health care environments. Accident and emergency departments traditionally
have nursing sta who are highly skilled in providing advice over the telephone. A criticism of
the service is that it is impersonal, not accessible
to everyone and not accepted. Calls in the accident and emergency department are usually answered by nurses who assess patients needs, may
provide advice for self care, prompt the caller to
seek immediate attention or refer the caller to
another health care professional or agency
(Crouch 1996). Telephone nursing has been
demonstrated as eective in a wide range of
clinical settings (Harris et al. 1991; Marklund
et al. 1991). Research by Marklund et al. (1991)
reported that 59% of out of hours calls required
telephone advice alone. However, Hallam (1997)
found in a survey of General Practitioners that
they disliked nurse led telephone helplines as a
form of care, particularly if they did not know the
patient.
Telephone advice by nurses has been shown
to be safe and eective in the healthcare setting
(Dale 1998). Balas et al. (1997) reported healthcare technologies can improve clinical processes
and patient care outcomes, reduce hospital stay
and improve and establish the relationship between the care giver and the receiver. Obviously
extensive thought must go into establishing a
telephone triage system. The sta involved must
be enthusiastic and knowledgeable and aware of
the potential benets and risks. Time is of major
importance when carrying out a planned telephone review, to ensure clarity of information
received and advice given. Condentiality must
by maintained and informed consent obtained.
Information technology departments have
developed systems for telephone triage; such as
NHS Direct where the TAS (Telephone Advice
System) is used. Dun (2000) reports that not
only are the technical aspects of information
technology important but the information it
gives must be timely.
The authors work within an Orthopaedic
Outcomes Team and are responsible for inuencing the care of patients undergoing total knee
and hip replacement. This is a total care system
for patients with nurse led telephone triage focusing highly in the pre- and postoperative period (OBrien et al. 1999). A 24-h telephone
helpline is rmly established with software being
developed in-house to record information related
to the patient. This is a very complex system and
has the facility to correlate data relating to trends
and complications relating to the patients surgery and satisfaction rates. The authors found
within their practice that telephone triage is an
integral part of their work. Patients report feeling safe and comfortable in the knowledge that
The development of telephone triage: historical, professional and personal perspectives 195
DISCUSSION
Nurse led services are a challenging aspect of the
extended role of the nurse. The use of the telephone for patient contact has shown to be successful and has the potential to become further
advanced. The publication of The Scope of
Professional Practice (1992) and the reduction of
junior doctors hours has had a far-reaching effect on the nursing profession. Section (9) of The
Scope of Professional Practice (1992) allows
nurses to expand their activity in nursing undertaking responsibility for a nurse led service.
The practitioner must acknowledge limitations,
thus ensuring the patients best interest is protected. Eective communication is a necessary
component in this process; nurses must be able
to justify their actions clearly and continue to
build on their knowledge and skills. Practitioners
base their decision-making skills on quantitative
and qualitative data obtained from the telephone
call. Skills are established and advance through
training, experience, knowledge and intuition.
Telephone triage is a service that will continue
to grow and public enthusiasm is encouraging at
a national and local level. Telephone healthcare
196
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