Investigating staff perceptions and experiences of telephone triage in general practice

Providing patients with improved access and excellent quality care is the aim of all NHS directives and the use of remote assessment is one way in which to develop practice in order to achieve this goal (Campbell et al, 2014). Telephone triage (TT) is a method employed by professionals to assess patients over the telephone to decide on the correct course of treatment for their ill-health, and this may involve self-care advice only, seeking a face-to-face GP appointment/attending a walk-in centre, or attending secondary care (independently or via an ambulance) (O'Cathain et al, 2004). Telephone assessment is not new and was primarily developed for use in out-of-hours (OOH) services across the world (Lake et al, 2017) and, in many cases, involves the use of clinical decision support software (CDSS) so that practitioners can standardise their triage and outcomes can be duplicated (North et al, 2014). Remote consultations using telephone/email and video assessments have increased exponentially in recent months following the impetus of managing care needs in general practice due to the COVID-19 outbreak (Marshall et al, 2020). Seemingly overnight, practices have changed the way their work is triaged and planned (Oldman, 2020).

The NHS Plan (Department of Health, 2000) increased the focus on quality in clinical practice and papers including Equity and Excellence: Liberating the NHS (Department of Health, 2010a) all echo the same ambition for improvement in standards. Primary care has had numerous changes since 2000 in terms of funding and commissioning, and general practices have become acclimatised to working in structures that have offered schemes of incentives (Ross et al, 2014). The three main objectives of NHS England (2018) for general practice in the coming 5 years are that staff should deliver better care, champion sustainability in general practice and utilise limited resources more efficiently.

Inter-professional collaboration is crucial to managing patient needs and the more recent development of advanced nursing roles has been pivotal in not only appreciating the contribution that the nursing workforce can generate but also in the ability to develop transferable skills, decrease duplication and extend nurses' scope of practice (Schober and Affara, 2006; Centre for Workforce Intelligence, 2013). In the UK, a degree of clarification was offered by the publication of the Department of Health (2010b) position statement on advanced level nursing, which identified the four pillars: clinical practice; leadership; research; and education (Nursing and Midwifery Council [NMC], 2010). More locally, the focus was very much on expert knowledge/decision-making skills and an expanded scope of practice following training at Masters-level study (Health Education England [HEE], 2017).

A home visit provides a platform for a health assessment in the patients' own home and, historically, GPs have undertaken all home visits in general practice, but with ever-increasing list sizes and the difficulties with recruitment of GPs, a niche role for experienced nurses has evolved to work alongside their GP colleagues. Arguably, patients request visits for a plethora of ill-health related queries and there is a significant contribution to be made by nurses trained in advanced health assessment to share some of the primary care workload.

Literature review

The majority of research reviewed details the use of CDSS, employed in every nurse-led clinic in America and common-place in the Netherlands (Smits et al, 2017) and OOH services in the UK. These computer-based frameworks aim to minimise variation and standardise the assessment of patients' issues while leading the triaging professional to a conclusion regarding advice. The systematic review by Bunn et al (2004) only considered studies that used CDSS and perhaps it was the case that when triage was developed, providing a platform for evaluation of practice and audit was one of the main drivers. Yet, there is evidence that CDSS can also be very restrictive and prevent patient's problems from being fully explored holistically (Murdoch et al, 2015a).

The second theme is role identity of the triaging professional and how this has changed through assessing patients over the telephone. Australian GPs detailed that they felt they had lost continuity with patients (McKenzie and Williamson, 2016) and it is easy to see why this would be the case, particularly in OOH where patients typically receive telephone advice only. The clinical background of each triaging nurse did not impact on decision-making in NHS Direct, although O'Cathain et al (2004) found that nurses with more than 20 years' experience were more likely to advise self-care compared to nurses with less than 10 years' experience. They concluded that professionals view of risk was what made the difference and that this provided the basis for more research.

The third theme of workload redistribution is timely as recruitment difficulties continue in general practice. At least 50% of telephone calls are thought to be managed by telephone advice only (ranging from 25.5–72.2%) (Bunn et al, 2004), with no adverse effects from this approach. Later, Murdoch et al (2015b) also found that both GP-led and nurse-led triage led to reductions in the numbers of patients needing to be seen face-to-face. Yet, evidence to demonstrate a cost saving is lacking, and studies detail that TT is a time-consuming and costly approach (Campbell et al, 2014).

The appropriateness of decision-making is the fourth theme to emerge from the literature and research by Pasini et al (2015) indicated that while GPs had not used a structure to conduct their TT, their decisions were correct. Details regarding what constituted a ‘correct’ decision and where this came from are not included but this demonstrates that professionals can approach triage from different angles and yet still conclude a diagnosis and appropriate treatment plan with the patient.

The final theme is one of the most important: patient satisfaction. Bunn et al (2004) state that their evidence found that patients were satisfied with TT, although it must be considered that this was undertaken primarily in 2004 and updated in 2009 at a time when TT was in its infancy and research was limited. Patient satisfaction with OOH TT services also needs to be considered against the context of this study, which takes place in general practice. While satisfactory in OOH services, researchers have found that patients are dissatisfied when TT creates an obstacle to traditional forms of care, i.e. face-to-face with a GP (Lake et al, 2017).

Aim

To explore how TT is perceived among ANPs and GPs, and to evaluate its impact on home visit requests in general practice.

Objectives

• Identify professionals' experiences of TT and their perceived barriers
• Explore ANP and GP views on their role and how this is developing in the context of the modern-day NHS
• To critically evaluate how patient expectations of home visits are managed by ANPs and GPs to agree treatment plans
• To formulate recommendations on how the use of TT could be improved in general practice in order to improve patient care and outcomes.

Methodology

Studying experiences of professionals and their personal views requires an approach that values their uniqueness and does not lend itself to statistical analyses but rather description of feelings. This study followed an interpretive phenomenological approach focusing on the perceptions of individual members of staff.

Research setting

The study took place in a general surgery partnership in the West Midlands. It consists of five practices with approximately 46 000 patients. A home visiting team has been developed across the partnership to manage the requests that come through from housebound patients each day Monday to Friday 8am–6pm. In order to provide anonymity for the surgeries involved, the health partnership will be referred to as the Evergreen Partnership for the purpose of this research study.

Population and sampling

The study used a purposive sample and due to the small number of nurses in the home visiting team, all three were invited to take part in the study to capture their perceptions of TT. One additional specialist nurse in the team was used to pilot the interview questions as this member of the team had been on a three-month induction period and had not been routinely triaging calls herself. All regular GPs who worked with the team received a letter inviting them to participate and the first five to express an interest were chosen. Random sampling was not appropriate for this study due to the small number of staff who had the potential to be involved and inevitably, this does not generally lend itself to qualitative studies where the focus is on the depth of findings which are more meaningful (Padgett, 2012).

Data collection

Data were collected via semi-structured interviews, which were audio-recorded and later transcribed by the researcher.

Ethical approval

Ethical approval was given by the university and an Integrated Research Application System (IRAS) application was completed for HRA approval due to inclusion of NHS staff. All procedures were performed in compliance with relevant laws and institutional guidelines.

Results

Colaizzi's (1978) method of data analysis was used focusing on the seven steps to identify meanings and ‘theme clusters’.

Step 1 and 2

The interviews were transcribed and coded, read and re-read repeatedly, followed by identifying significant statements that related to the topic. The coding for this process followed the approach by Wirihana et al (2018) and detailed the page number of the transcriptions (P1, P2 etc), the paragraph location (P1, P2, P3 etc) and the participant identifier. The nurses were assigned N1, N2 and N3 and the doctors were assigned D1, D2 etc.

Step 3

The significant statements led to the development of meanings; an example is included in Table 1.

Step 4

There were 89 significant statements from the transcriptions that led to 16 theme clusters, an example of which is shown in Table 2.

Step 5 and 6

This involved developing an ‘exhaustive description of the phenomenon’ by fusing all of the findings together (Colaizzi, 1978) and developing an abstract description of TT (Wirihana et al, 2018).

Step 7

The final step was participant validation, which involved emailing the participants a copy of the findings to receive their comments.

Discussion

Theme 1: TT use requires training and support

The development of telephone triage in this study relies on clinician assessment over the telephone without a formal structure to follow. There is no doubt that CDSS standardises practice and documentation related to assessment, but it must be acknowledged that, in most cases, it is used to provide telephone advice only and to direct the patient to where they should be seen (North et al, 2014). There was an acknowledgment that experience of triage led to reduced anxiety, and the study by Murdoch et al (2015b) concluded that perception of TT affected how staff felt about its introduction. The level of support offered to staff cannot be overlooked. The Murdoch et al (2015b) RCT also found that staff in primary care did not feel that the use of CDSS was appropriate for them and often missed some of the key aspects of assessment; whereas it was shown to be beneficial within OOH services. Anxiety reduction by increased experience was stated by all of the nurses in the O'Cathain et al (2004) study and in this study, with N1 explaining that:

‘…we were forced into situations that challenged us, we were forced into making telephone calls that we weren't sure about and whilst that was uncomfortable, I felt I actually learnt a lot from that…’

D4 stated:

‘However confident you are, regular training is important, listening to your own consultation, we don't do it here…’

TT is commonplace in the Netherlands and nurse education for triage is mandatory, including regular audits (Huibers et al, 2012). It could be the case that practising TT skills could improve abilities and help to standardise approaches to TT that have not previously been considered. Staff would inevitably feel uncomfortable going through this process, but may learn a great deal from shared learning as long as this was constructive.

Theme 2: TT is a useful tool to manage demand more efficiently

This theme was universally stated by all participants and, perhaps, reflects the need for modern ways of working in the current NHS. The general benefit was that TT increased clinician control over their day, allowed the prioritisation of the sickest patients and also enabled care planning to begin right from the initial contact, so that the most efficient use of time was enabled and the right clinician saw the right patient.

Theme 3: Communication and patient engagement are barriers

Barriers to successful TT included issues around patients not hearing professionals very clearly on the telephone and those that struggle with verbal communication. One of the wider barriers was staff concern about patients providing an accurate history so that an effective treatment plan could be agreed.

Theme 4: Patient expectation for a home visit drives decision-making

There was experience of conflict of opinion with patients and a number of the doctors felt that they had spent a lot of time in the past arguing why a visit was not needed, where it may have been quicker to simply do the visit and discuss the outcome afterwards with the patient. Similarly, Turnbull et al (2011) identified that patients were able to influence decisions during what should be a negotiated consultation. The literature confirms that TT use changes the doctor–patient relationship of the past (McKenzie and Williamson, 2016). This is a reflection of changes in general practice where doctors have historically been the main health professionals with a few practice nurses working in the surgery. This is not the case now where it is commonplace for large multidisciplinary teams to work together.

Patient involvement has been high on the governmental agenda for many years and this is another way in which primary care can develop this further. D3 discussed explaining to patients that:

‘…primary care doesn't work that like that anymore… we should be working towards the same goals with shared plans… and I think patients have to accept that GP resource is going to be used differently.’

Both D2 and D4 concurred by stating that agreeing a way forward and negotiating a plan was imperative and this would enhance safety in care organisation.

Theme 5: Staff are striving to make changes to their roles and develop new ways of working

Perhaps not surprisingly, staff did acknowledge that they all felt under pressure to manage their workloads which for some participants included mainly clinical work, and for others more managerial aspects of their role. Clinicians acknowledged that TT came with a certain level of risk because patients were not being seen face-to-face. D4 went on to say:

‘…some people feel that there are additional cues that we miss out on with TT, for example, the non-verbal cues we cannot see. We all have our gut instinct when you see a patient… the patient comes in and they look ill.’

N3 agreed that not actually seeing the patient created some uncertainty about the assessment and N2 found the change in practice ‘unsettling’ initially. An interesting point raised by a number of participants was that telephone triage is seen as telephone consultation. The literature concluded that the term ‘telephone consultation’ appeared to be used interchangeably with ‘telephone triage’ (Bunn et al, 2004), which is not what the participants in this study felt. D1 stated:

‘I prefer to call it telephone consultation, um, triage is purely a sifting operation isn't it onto this pile, that pile or that pile, whereas actually, I'm trying to treat these people, I'm trying to listen to their concerns, diagnose them, treat them if I can or do the next thing.'

McKenzie and Williamson (2016) identified that telephone assessment suited some professionals' personalities more than others and perhaps this explains some of the differences in opinions from the participants in relation to their view on how it is used and evaluated.

There was also discussion about how care could be improved and many participants discussed the progression of digital technology as enabling this to move forward. Discussion about NHS apps and Skype consultations were discussed, where patients could send photographs of a rash or lesion, for example, which would offer assessment visually. There was a general feeling about IT structures between primary and secondary care and that improvements may lead to a timely sharing of data which would impact on requests for tests/changes to medication regimes and provide discharge information.

Theme 6: ANPs are a valuable part of the home visiting team and successful practice needs teamwork

Taking on new roles and extending the scope of practice by nursing staff was an expected development for the participants and, likewise, the doctors in the study all felt that their roles had evolved immensely in the years that they had been practising. N1 advised that:

‘…as the role's developed, as the team has developed, as I've become more experienced as an ANP, it's kind of become a natural progression… provided we have the GP backup and support, I think that's enabled us to flourish as ANPs’.

N2 agreed by stating:

‘I think all advanced clinical practice roles evolve and change to suit and adapt to the environment, I think as nurses, we're very good at that.’

N1 stated that, initially, there were complaints from patients who were expecting a doctor at the door rather than a nurse, but that this has improved greatly now and patients welcome the ANP visits. N1 stated that:

‘it was the case that once you'd been in and done an assessment and the patients understood what our skill set was, we were home and dry and often the ANPs are more popular than the GPs.’

The view on teamwork was shared among many participants who agreed that general practice cannot exist in its own sphere and requires a mixed multidisciplinary approach to manage all aspects of patient need. D5 stated:

‘…the list size has grown massively, the team of people providing the clinical care has diversified and grown. The services that we offer… are much more now than they were… I think my role more than just seeing the patients is more about working as a team, to some extent leading the team…’

The theme that working together provides the best outcomes was agreed on by N3:

‘…you definitely need a GP… sitting with the team… working it within a team environment, lots of people with lots of knowledge in the one room that you can bounce ideas off and ask questions…’

Limitations and strengths

The small sample size was inevitable as the study was conducted in one partnership; however, this was unavoidable as the study required a group that were using TT to assess requests for same-day home visits. Researcher bias is also a fundamental risk of semi-structured interviews where the interviewer is an evident contributor in the collection of data (Harding, 2013). As already detailed, there is a lack of research focusing on the use of TT in primary care rather than OOH services and, hence, this study was not replicating work already completed but was unique in the locality.

Arguably, the use of Colaizzi's (1978) method of data analysis improved the trustworthiness of the themes and, additionally, step 7—which involved participants validating conclusions—helped to increase the accuracy and credibility of responses (Wirihana et al, 2018).

Conclusions and implications for practice

• Teamwork can foster shared learning and responsibility in decision-making when using TT
• Training can develop skills including reviewing consultations or using case studies
• TT use is increasing, but each practice needs to consider what will ‘best-fit’ their area
• Change needs support/involvement at all stages to minimise anxiety and foster confidence
• Future research could focus on the use of TT in primary care, investigating conversion rates, cost reduction and impact on face-to-face appointments
• Future research could ascertain patients' experiences of this approach in managing their care.

TT offers staff a way of assessing patient need for face-to-face assessment or home visits remotely. Clinicians felt that it offered a way to structure their days more efficiently and to prioritise the sickest patients first. Experienced clinicians bring a wealth of expertise to their work environments, which can support team learning and help to foster shared responsibility for clinical decision-making. The changes during the COVID-19 crisis offer a real opportunity for general practice to further evaluate telephone triage and telemedicine going forward (McCartney, 2020). While demand for home visits outstrips capacity, new ways of assessing patients to effectively use clinical time, creating shared treatment plans with patients, is crucial if quality is to be improved.

CPD reflective practice

• Consider your experiences of triaging and assessing patients, what barriers have you encountered and how have you overcome them?
• How does your day-to-day experience of team working benefit you, your colleagues and your patients?
• Do technological advances impact on your clinical day at work and how can these developments be utilised to improve patient care in your work environment in the future?

KEY POINTS

• Telephone triage (TT) offers staff a way of assessing patient need for face-to-face assessment or home visits remotely
• TT use requires training and support for staff
• While communication and patient engagement can be barriers, teamwork is a valuable means of improvement