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Telephone consultation and risk management

Judith Roberts
RGN RSCN MA PGDip
Senior Lecturer PCD
Edge Hill University
Liverpool
Senior Lecturer and Module Leader of new module "Principles of Telephone Consultation"
For course enquiries please contact robertsj@edgehill.ac.uk

Using the telephone to talk to patients is hardly uncommon. Receptionists and appointment clerks do it all the time. Increasingly the telephone is used as a mode of access between the health professional and a member of the public.(1) For both parties, using the telephone to contact each other might seem a rather convenient and efficient way to get an answer to a health-related question.
Undertaking any clinical assessment of a patient is difficult enough, doing it safely when one cannot see or examine the patient is even more demanding. Furthermore, just because using a telephone is a common experience, it does not mean that every health professional can automatically adapt their communication and consultation skills to this mode of access.
It is recognised that the skills needed to undertake this role are "complex and multifaceted",(2) and that training and development is necessary to reduce the risks inherent in this type of contact.(3,4) Yet there are few workshops or university programmes available.
This series intends to partially address the issue by suggesting a suitable framework to structure a call and various strategies to promote effective communication, clinical assessment techniques, clinical supervision and governance. However, the limitations of an article in a journal must be recognised, for it is no substitute for a formal development programme or robust ongoing monitoring and clinical governance activities.

Some of the risks associated with telephone consultation

  • Obviously, not being able to physically examine and observe the patient.
  • If not able to observe the patient, an accurate assessment is very dependent upon the patient's ability to give clear descriptions of their signs and symptoms. However, the patient's ability to communicate can be hampered by numerous factors including anxiety, pain, ill health or disability, as well as their fluency and breadth of vocabulary. For people for whom English is their second language, telephone conversation is especially difficult.
  • Patients do not always recognise the significance of their signs and symptoms and may not report them voluntarily. In the clinic setting clinical examination and interpretation of nonverbal cues compensates for this. However, over the telephone the practitioner must concentrate and actively listen, then be deliberate and precise in their questioning, probing any sign of ambivalence or uncertainly.
  • Inadvertent breaches of confidentiality may occur so legally, before starting your assessment, you need to ensure that you are speaking to the patient and not a relative with the same name. Check with the patient their name, date of birth and address before proceeding. Indeed as far as possible it is best to overcome any caller resistance and speak directly to the patient. Not only does it negate any breaches of confidentiality, but it will also lead to a far richer, more accurate history taking. A relative, due to anxiety, may be guilty of symptom hyperbole, or for varying reasons, may be dismissive of the severity of the patient's symptoms.
  • If using a computer to record the assessment, the practitioner must be able to navigate the IT software/record-keeping system confidently so that a lack of competency (in software use) does not hamper the call-handling process, the interaction with the patient, nor the formation, storage and transfer of accurate contemporaneous documentation.
  • Each decision is an autonomous decision by the clinician. Unless they ask for advice, or the patient is referred for further assessment, their decision is not endorsed by any other health professional. There is no other safety net as in clinic settings when sometimes it is a colleague's concern that alerts us to something that perhaps we may have missed.
  • Pressure for efficiency (got to get this queue cleared) can always compromise a clinician's judgment, but in a telephone consultation role, with so many channels of communication unavailable, it is imperative that the practitioner uses active listening skills, and manages their concentration levels - if necessary, taking short breaks to both rest their eyes (if looking at a computer screen) and their brain.
  • Telephone consultation can be an intensive, intellectually-demanding activity. Limited visual stimulus/call variance will hamper the practitioner's recall; therefore it is vital that accurate records are completed which include the rationale for the nurse's decision. The record should include a brief summary of the questions asked and the patient's response including any negative findings, such as no pyrexia, no rash and so on.
  • Patient outcome is a major learning point for any clinician. However, in telephone consultation, once the patient is given self-care advice, the care episode is closed. Therefore the practitioner has limited if any feedback. This will hamper reflection and evaluation especially if there is no regular clinical supervision in operation.
  • As the telephone consultation process is purely between the practitioner and the patient there is also limited opportunity to benchmark practice or share learning with multidisciplinary colleagues.

Despite these risks and deliberations, telephone consultation, undertaken by specifically trained and supported nurses, has been assessed as a safe mode of access.(5-7)
As primary care grapples with the pressures of managing out-of-hours services,(8) meeting the needs of patients with long-term conditions,(9) and the service development required due to the shift of services from secondary care,(10) it is increasingly likely that some aspect of telephone consultation will become more prevalent in nurse job descriptions, including those of practice nurses. This development is likely to be accelerated in some geographical areas by a reduction of GPs.

Professional accountability and preparation for practice
The roles described in Box 1 vary in their complexity and clinical urgency, but for even the simplest task there are a number of factors that need to be considered before the practitioner picks up the phone. Mindful of their professional accountabilities, the practitioner must objectively self-assess their competency to carry out this aspect of their role and actively consider how they will adapt their practice to this medium.(11)

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A note of warning is needed. Telephone consultation is already a demanding environment in which to perform, and the clinical risk increases if the practitioner is not only new to telephone consultation, but is also new to the role it is being used for, eg, triaging patients. Trial and error is a common learning method - after all, it is probably how most of us learned how to use a mobile phone - but it is not appropriate or justified in clinical situations for it can expose the patient, the practitioner and their employer to unacceptable clinical and professional risk. As a minimum there should be additional training for the role supported by the use of protocols devised by the clinical team.

So what do you need to know before carrying out telephone consultation?
Obviously it will depend upon the reason why you are calling the patient, but job descriptions often mention the following:

  • Knowledge of the patient group characteristics and demographics, eg, norms of child development milestones if working with children.
  • Awareness and recognition of immediate life-threatening conditions and basic first aid advice.
  • Clinical assessment history taking processes.
  • Active listening and questioning techniques, using interpersonal skills to establish rapport and allay patient anxieties.
  • A breadth of knowledge related to the common and less common clinical conditions that the patient may wish to discuss, with a good understanding of possible differential diagnoses and disease presentation.
  • Documentation and recording processes.
  • Basic keyboard skills.
  • Local sources of referral, access arrangements and other sources of health information support, and advice for the patient and you.
  • Awareness of relevant policy and procedures, eg, child protection vulnerable adult, protection of confidentiality, from faxing policy, to what to do if an answer phone is in operation, do you leave a message or not?

Another way to determine the role responsibilities and requirements is to benchmark the proposed new role against a checklist that has been "tested" by the NHS, for example, the NHS Agenda for Change national job evaluation profiles for NHS Direct nurses. It is also worth noting that the role attracts an NHS pay band (see www.nhsemployers.org/pay-conditions/pay-
conditions-1991.cfm and scroll down the page to the NHS Direct section).(6)

Preparation for practice
At this point the potential new practitioner should self-assess their existing skills against the above criteria. Any area of self-doubt should be tested in "role play" and suitable training and development arranged. Even if the person feels well equipped, they will still need induction, mentorship and formal monitoring.
A special consideration - If you are new to the role or if you have to use specific software packages (eg, clinical decision software, or patient records or equipment, eg, telephone systems and computers) it is the responsibility of your employer to arrange the necessary training. As an employee it is your responsibility to attend the training, make reasonable efforts to learn the new skills and to advise your employer (in writing) if you still feel unable to perform the role competently at the end of the training.
If you do not express your concerns and start doing the role, it will be legally assumed that you are accepting the accountability that comes with it.
In the next issue I will concentrate on the telephone call itself and propose a systematic framework for the process. I will also suggest a series of activities and resources, that will help both the novice and experienced practitioner to promote their own clinical supervision, audit their interventions and thus provide evidence of the governance of this clinical activity within their practice.

References

  1. Royal College of Nursing. Telephone advice lines for people with long-term conditions. London: RCN; 2006.
  2. Wilson R, Hubert J. Resurfacing the care in nursing by telephone: lessons learned from ambulatory oncology. Nursing Outlook 2002;50:160-4.
  3. Medical Protection Society. Inappropriate advice. Case Reports 2005;13(4). Available from: http://www.medicalprotection.org/uk
  4. Car J. Sheikh A. Telephone consultations. BMJ 2003;326:966-9.
  5. Lattimer V, George S, Thompson F, et al. Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. BMJ 1998;317:1054-9.
  6. National Audit Office. NHS Direct in England. London: The Stationery Office; 2002.
  7. Richards DA, Meakins J, Tawfik J, et al. Quality monitoring of nurse telephone triage. J Adv Nurs 2004;47:551-60.
  8. Department of Health. The national quality requirements in the delivery of out-of-hours services. London: The Stationery Office; 2004.
  9. Department of Health. Supporting people with long term conditions: an NHS and social care model to support local innovation and Integration. London: The Stationery Office: 2005.
  10. Colin-Thomé D. Keeping it personal. London: Department of Health; 2007. Available from: http://www.dh.gov.uk/publications
  11. NMC. The NMC code of professional conduct: standards for conduct, performance and ethics.  London: NMC; 2004.