The introduction of nurse led telephone triage has substantially changed nursing practice, creating new skills but also the risk of losing some, according to researchers.
Over the last few years nurses have increasingly become involved in telephone triage. As well as NHS Direct, the government set up the National Pandemic Flu Service hotline last year in response to swine flu and some large companies use nurse triage to deal with staff sickness.
Nurse researchers reviewed 16 studies, including four on NHS Direct, the results of which are due to be published next month in the Journal of Advanced Nursing.
Lead author Rebecca Purc-Stephenson, from the faculty of nursing at the University of Windsor in Canada, said telephone triage meant nurses adhered to call-centre ways of working, which were very different to clinical settings, and were unable to physically examine patients.
She said: “Telenurses often felt they had developed new communication skills including listening to verbal and non-verbal clues, like tone of voice, breathing, words and expressions used and general conversational tone.”
However she added that some nurses also felt constrained by call centre style protocols – for example NHS Direct uses decision making software to guide the consultation – instead of being entirely free to use their clinical judgement.
The authors highlighted examples of nurses overruling the protocol and using their own clinical knowledge “if the final automated outcome was deemed inappropriate”.
NHS Direct chief nurse Helen Young said the software was there to support nurses. She said: “Our nurses are highly trained professionals and are required by us and the NMC code of conduct to use their clinical judgment when dealing with patients.”
The researchers also said telephone triage nurses faced a dilemma between giving appropriate advice on seeking further clinical assessment and pushing patients towards other overstretched parts of the healthcare system, according to latest research.
Since its inception there has been a common belief that NHS Direct too often recommends callers go to A&E or their GP – leading to suggestions that it creates demand rather than reducing it.
The authors concluded that “telenurses” experienced a range of concerns, often around the availability of other services. They said: “Final triage decisions are influenced by balancing the conflicting demands of being both carer and gatekeeper to limited healthcare services.”
Ms Young said latest figures suggested that in around 60 per cent of cases NHS was able to provide advice to callers on how to treat themselves at home without needing onward referral.
She said: “Providing our patients with the most appropriate advice has always been our main priority and we work with other NHS services to understand the pressures that are facing them.”