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A framework for telephone nursing

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VOL: 97, ISSUE: 16, PAGE NO: 36

Rosalyn Moore, MA, BSc, is deputy director of nursing/lead nurse, NHS Direct, West Yorkshire

The role of nurse adviser at NHS Direct, a service providing year-round, 24-hour telephone information and advice, is an attractive career option for senior nurses from a range of clinical backgrounds.

The role of nurse adviser at NHS Direct, a service providing year-round, 24-hour telephone information and advice, is an attractive career option for senior nurses from a range of clinical backgrounds.

Practice at NHS Direct is varied and demanding and draws on the general or specialist experience that each nurse brings to the post. Although the advisers work autonomously they are supported by peers and a computerised assessment system, which is essential with such a complex caseload that spans the entire spectrum of age and need.

There is no ideal background for the role, but nurses must be able to work independently and have the confidence to operate within a framework of clinical, professional and legal accountability.

Development of the framework
The framework was developed by NHS Direct in West Yorkshire - part of the West Yorkshire Metropolitan Ambulance Service NHS Trust - and reflected the culture of innovation, excellence, empowerment and self-management that was already in place there. It was also timely in that it enabled NHS Direct to meet a number of local, national and professional policy initiatives.

Nurse advisers at NHS Direct deal with patients over the telephone using a computer-based clinical assessment support system (CASS) to help make decisions. However, the telephone and CASS are merely tools and are not the focus for the nursing. This is an important distinction in view of certain common misconceptions about the role.

The framework was initially developed by a group of expert nurses. From the outset it was agreed that the position of nurse adviser is consistent with the competencies of a senior registered practitioner (Department of Health, 1999). The guidelines recommend that:

- The existing knowledge, skills, experience and seniority of the nurses are acknowledged;

- Nurses should be given and be prepared to accept responsibility and accountability;

- The framework should promote empowerment and self-management and support non-hierarchical structures and working practices;

- The role of leaders and managers should be to provide clear boundaries, articulate expectations and help nurses to perform at this level.

Defining the competencies of nurse advisers
Once the guiding principles and components had been agreed, a role analysis enabled the purpose of the role and the nursing outcomes to be identified. An integrated, holistic definition of competence was adopted in which the need for clinical expertise and professional judgement in the role was acknowledged. Integrated competence has been described as 'the complex combination of knowledge, attitudes, values and skills necessary for safe, intelligent performance in specific situations. It acknowledges the importance of professional judgement, clinical reasoning, ethics and the fact that there may be more than one way of practising competently' (Hagar and Gonczi, 1996).

A model for nursing practice
It became clear that concepts described in Peplau's model of nursing (Aggleton and Chalmers, 1990) were relevant and applicable to practice in this setting. Peplau's model focuses on the development of interpersonal relationships between the nurse and patient (Walsh, 1991). It also promotes patient independence and empowerment, which is seen as crucial in this context.

Nurse advisers are in a unique position because each care episode is short and depends on the rapid building of a relationship to forge partnerships with patients and help to meet their needs. The model describes four phases in this relationship: orientation, identification, exploitation and resolution (Box 1). These phases can overlap and together constitute the care process (Walsh, 1991).

Nurse advisers adopt a range of roles and must be skilled at moving in and out of these roles in response to different factors, including patients' needs and progress within the care process. With each phase, the nurse and patient work together to meet the patient's health needs. The nurse negotiates mutually agreed outcomes, encouraging patients to take charge of their own health.

Nursing roles
Peplau describes a variety of roles that are relevant to the position of nurse adviser at NHS Direct. Six role dimensions have been identified (Fig 1). 'Stranger' (establishing effective interpersonal relationships); 'resource' (providing useful information, advice or expertise); 'researcher' (finding information and developing practice); 'care manager'; 'leader/facilitator'; and 'educator' (educating the caller, developing self and others).

These dimensions are applied in practice, through the phases of identification, orientation, exploitation and resolution. They are also applied through delivery and development. This involves team effectiveness, learning, the management of resources, practice and service development, quality and the promotion of health (Fig 1).

The framework
The framework is a comprehensive description of the nurse adviser's role, expressed as integrated, outcome-based competencies. It starts from the point of role outcomes, as opposed to role functions.

Because it is based on nursing outcomes, it has the potential to generate knowledge and theory for an area of practice that is yet to be defined and to guide educational development and provision (Fig 2). It also underpins reflective practice activities and professional supervision, makes role expectations clear and offers standards for the critical review of performance (Fig 3).

Role and career development
The framework incorporates a set of core competencies for the role, which guide the nurse's journey from recruitment, induction and preceptorship to independent practice. The role and career development are taken into account with the inclusion of enhanced competencies in the areas of managing services, developing people, quality and clinical effectiveness.

Nurse advisers develop an area of enhanced competence in line with service demand, as agreed through performance development review (PDR).

Progress to date
The framework is being used with nurse advisers at the West Yorkshire site and there are plans to extend the work to other groups of staff. The programme was also recently piloted across three sites in the Northern and Yorkshire region and has been subjected to a rigorous evaluation process. Nurse leaders and practitioners have welcomed the framework and plans for national implementation are being considered.

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