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NHS Direct has 'changed nursing practice'


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.”


Readers' comments (6)

  • NHSD is a useful system. It uses a computer program to enable a nurse to come to a decision. If the nurse is unhappy about the outcome, she/he can override, but then has to justify why in her closing text. If the nurse needs reassurance it can be sought from one of the many "managers" that will be on duty at any one time.
    There are many senior and experienced nurses working within the system and there are also many junior, inexperienced managers. Nurses call rates per shift are monitored and the nurse is interviewed if the rate falls. A call is expected to take about 8 mins. If the nurse needs to leave the desk, then a code, which gives the reason for the absence, must be dialed into the phone system. Calls are headed up on the monitor in front of the nurse and when selecting a call it must be the call at the top of the queue, even if it is a paediatric call and the nurses' experience relates to say orthopaedics. A paediatric nurse may well be sitting alongside but then has to take an ENT call. How can experience be used to make a nurse aware that a computer outcome needs to be overridden. When dealing with a Psychiatric patient, the call can take any amount of time. This will not be taken into account however when call rates are examined by the team leader and the nurse may well be given a warning.
    I worked for NHSD in the early noughties.

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  • I work as a NP in general practice, and I suspect from personal experience that a truer picture would be that it partly helps relieve pressure on services and partially causes some of that pressure -some clients feel their health concerns are dealt with appropriately and some are dissatisfied with the advice given and subsequently approach their GP service the following day for clarification, creating demand. This has been my personal experience with my own children and the experience from the patients. Even if the advice given is correct, people often feel the need for rreassurance from a person face to face rather than a faceless voice.

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  • Further to my comment above about having the inexperience to override a computer diagnosis, for want of a better word, I see today the the Chelmsford NHSD based in what was the Essex Ambulance Headquarters is recruiting staff now at Band 5, so, no experience whatsoever to override.
    The nurse's career experience is a safeguard for when the computer gets it wrong. A human response to sometimes complex, inaccurate information being given by an exteamly worried other human.

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  • I currently work for NHSD and feel we give a good service all round. However the advice we give is just that, advice and callers are free to follow it or not.
    In reply to comment by Ellen Nicholson NP. We too get calls from patients that have visited their GP yet ring us for a second opinion, to which advice would be given that if concerned about GP advice then to revisit surgery and ask questions, we would never over rule GP advice.
    In reply to anonymous 25-Feb-2010 10:58 am, some NHSD sites are recruiting band 5 nurse, but as far as I am aware they will take lesser prioroty calls, leaving more experienced nurse to deal with the higher priority (urgent calls). Band 5 nurses are still experienced nurse and have the knowledge to decision make.

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  • Anonymous | 24-Feb-2010 1:57 pm:
    you are very diplomatic in comparison with my experience in recent years. I left because of institutionalised bullying from all levels of management and how the system is set up to support and condone it. We were unable to alter any outcome actions without being 'interviewed' as to why, despite being band 6 and 10 years experience of acute/critical care. Any sense of holistic approach or deviating from the single minded questioning technique was seen and treated as bad triage whence I was continually put on review and training schemes, ignoring the 'gold' standard of all of my calls and advice! Every other nurse there was unhappy and depressed/distressed at how they were treated. Having left and worked for a local GPOOH service I'm staggered at how narrow minded, ill designed and unsafe the NHSD system actually is, although the initial call handler stage is very good. I completely disagree with the above comment (!), there are some things NHSD does do well, eg. health info, dental, comfort calling and call prioritisation to a degree, but a good all round service it is not. It is also in my experience the unhappiest job I have had.

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  • I have worked in NHS Direct for many years and during that time I have met and worked with some of the countries best nursing colleagues. Unlike the perceived experience of one of the other reviewers I have always been fully supported in my role and have been encouraged to develop myself both personally and professionally. NHS Direct has afforded opportunities to me that I might otherwise not have had. The majority of patients using the service are highly satisfied with the care and the advice that they receive and NHS Direct benefits from sate of the art technology and pleasant working environments. NHS Direct is there for patients when many other services are closed and can offer the reassurance and advice that many callers need or who would otherwise present in A & E, for example. NHS Direct places a strong emphasis on clinical excellence and in my experience nurses working for the service are committed individuals who all want to do the best for their patients. NHS Direct might not be for everyone, the same as some nurses are not suited to other specific areas of care, but it would be fair to say that NHS Direct has successfully developed a number of nurses and equipped them with transferable skills that will benefit them in any clinical setting. Remember also the skills that NHS Direct nurses have and go on to acquire, i.e assessing patients over the telephone who may present with any one or a number of symptoms / conditions. I am bemused by the reviewer who suggests this is not a ‘holistic approach’ as in my experience it is.

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