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The telephone consultation process: part II

Judith Roberts
RGN RSCN MA PGDip
Senior Lecturer CPD
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

In my last article (NiP 2007;35:75-7) the increasing use of the telephone to contact patients was discussed and its risks examined. Risk-reduction strategies of suitable role specifications, service development, training and experience were illustrated.
This article assumes that the practitioner and their service have decided to adopt telephone consultations. Therefore guidance will be offered regarding the format of a safe and successful telephone consultation, indicating further resources that will inform practice, service delivery and its governance. The following advice has been informed by existing guidelines combined with the normal face-to-face history taking requirements.(1-4) Additionally Peplau's theory of interpersonal relations in nursing has three distinct stages: orientation and identification, exploration and resolution.(5) These stages can be directly applied to a telephone consultation, and help to structure the process (see Table 1).

[[nip36_78_table1]]

Orientation and identification
All clinical activity is time pressured, but it is important that you are both efficient and effective. A clear voice and welcoming tone are helpful, but must be combined with a structured approach where you "direct" the patient through the conversation. This prevents patients from giving too much or inappropriate information and helps to structure your clinical decision-making. If the patient is anxious or angry, your open professional manner should be sufficient to defuse the situation.
Ensure that your "direction" is about the call process and your clinical analysis remains open to all potential possibilities. In such a "cueless" environment there is a greater risk that you may make assumptions that lead to premature and possibly inaccurate decisions.(6)
Legally, you should speak directly to the patient. Not only does this give direct consent, it also empowers them to look after their own health and helps you to gather clinical information, eg, their degree of breathlessness. If this is not realistically possible, it is best to check that the patient is aware of the call and present with the caller. If you cannot speak to the patient this should be documented in your call record.

Exploration
Here you will carry out the main body of the assessment. You will need a good understanding of the possible differential diagnosis and typical and atypical disease presentations. Start to question the presenting complaint using a standardised approach. Clinicians often use acronyms to structure their thinking (see Box 1 and 2). This may be of value especially if you do not use clinical decision software or care pathways.

[[nip36_79_box1]]

[[nip36_79_box2]]

Other clinically significant information
Answers to the questions in Box 1 will not give you all the clinically relevant information you need. You should also check for any possible "red flag" symptoms, linked to the possible causes in Box 2. For example, when dealing with a patient with diarrhoea, ask: "Is there any bleeding, meleana, weight loss or reduced urine output?" If the patient has a rash, ask: "Does it blanch, is there any inflammation, fever, recent immunisation or stridor?"
Consider: is the symptom systemic or localised? One swollen ankle could indicate an injury while both ankles swollen could signal worsening heart failure
Are there any significant risks? Is the patient's health already compromised by a long-term condition such as diabetes or a congenital problem? Consider pack years if the patient is a smoker, and occupational impact, communal contact at school or nursery and any recent travel abroad. If it is relevant to the call and the risk assessment, you could ask about the patient's alcohol intake.
Assess what impact the symptoms have had on the patient's daily life to judge both symptom severity and to contextualise subjective statements.
Probe the patient's resourcefulness and self-care efficacy. What do they intend to do and what have they already done to manage the situation?
Consider: does the caller's anxiety about the symptom need to be addressed more than the symptom itself? Remember that parental or carer anxiety is a sufficient trigger for referral.

Questioning technique
It is vital to gain this type of accurate and detailed information. Listen actively, reflect, repeat, paraphrase and summarise. Your questions should be open, and verbal nods such as "humm, mmm, oh" can indicate that you are listening.
Partially qualified answers should be followed up. You may ask: "Do you have a headache?" and the patient may answer: "Errr no, not really". You can then ask: "What do you mean by 'not really'?" Negative leading questions such as "You don't have … do you?" should always be avoided. These may direct the patient to confirm no when in fact they mean yes.
With experience you will learn to use your "ears for your eyes", varying your questioning to get a "picture" of what is going on.7 Just remember, not all patients can map out their anatomy, use or understand clinical terminology or clearly describe their symptoms. If the patient is a poor historian, try to regularly summarise and reflect back their answers.

Resolution
At this stage the assessment has ended but you will need to communicate your clinical decision, offering care advice, seeking agreement and advising the patient of the next stage of action.
Your clinical decision about the outcome of the call will be affected by a number of variables: clinical risk, patient self-care efficacy, available resources and even the time of day. For example, can you help the patient "cope" overnight until they can make an appointment to see the GP in the morning?
Summarise and justify your decision to the patient, sometimes a very ill patient needs your explanation why they need to urgently see a clinician and sometimes patients need to be told why you think their symptoms do not warrant an immediate appointment. In both situations record the rationale behind your decision and the outcome. 
If you feel the patient does not need to be seen by a clinician you will need to give them care advice and worsening instructions. These should be sourced from evidence-based information (see suggested websites) and should follow health promotion principles. If you have used information from a website to guide your advice then record which site you used.
When advising about the use of over-the-counter medications, eg, paracetamol, make sure you give clear instructions relevant to the age of the patient and the type of preparation. You can also suggest they seek further advice from a pharmacist. Again record the advice you have given. 
Once you have mutually agreed the outcome of the call, ensure the patient is fully satisfied and then safety net the call by giving specific worsening instructions and call-back advice.
Complete all necessary documentation making any referrals as per existing policies and procedures. If you are fortunate enough to see the patient as part of their follow-on care, you can then assess and evaluate the decision you made over the phone.

Clinical governance: methods, strategies and resources
Given the risks inherent within telephone consultation it is imperative that suitable clinical governance strategies are decided upon and put in place before carrying out a telephone consultation.
Taken from Department of Health policies and professional guidance the following is a brief list of suggested governance activities.(1,6,8- 11)
Operationally

  • Review and adopt advice from the above sources.
  • Ideally all calls should be audio recorded as per national guidelines.(8)
  • Senior staff need to agree specific call process/care pathways relevant to operational functions.
  • Devise a call review/audit tool based on the above proforma and use it to assess each clinician at agreed intervals in order to monitor calibre of practice and to offer appropriate support.
  • Ensure agreed evidence-based resources are used to inform care advice and practice.
  • As part of wider service monitoring, investigate complaints and incidents and consider using customer satisfaction surveys.

Individual staff

  • Ensure you get the necessary training with mentorship and use agreed protocols.
  • Recognise the persistent risk within every telephone consultation and practice cautiously with a "bias towards face-to-face assessment where there is any potential cause for concern".(12)
  • Find out about the outcome of your call reviews, or if not undertaken as frequently as you would like ask a colleague to listen to your calls and give you feedback. (You will need to gain the patients consent and ideally use an adapted headphone so you can both listen simultaneously.)
  • Use  your call review results and call outcomes combined with your own reflections within monthly clinical supervision sessions.
  • Ultimately, use this information to inform annual appraisal and personal development plans and Knowledge and Skills Framework reviews.

Conclusion
Given service demands and a population that are increasingly confident users of all communication media, it is expected that telephone consultations will only increase. Therefore you will probably need to adapt your practice so you are able to safely nurse over the telephone.
If you are worried that you may lose the "personal touch", a final quote may help to eradicate your fears:(13)

"Nothing could be more modern - and more unlikely - than nursing on the telephone … The foundation of good nursing is the personal connection between nurse and patient or nurse and carer. My experience showed me, to my surprise, that it does not have to be face to face."

References

  1. Royal College Of Nursing. Nurses telephone advice consultation services - information and good practice. London: RCN; 1998.
  2. Moore R. A framework for telephone nursing. Nursing Times 2001;97:36-7.
  3. Car J, Sheikh A. Telephone Consultations. BMJ 2003;326:966-9.
  4. Douglas G, Nicol F. Macleod's clinical examination. 11th edition. Edinburgh: Churchill Livingstone; 2005.
  5. Peplau HE. Interpersonal relations in nursing. New York: Springer; 1991. (Original work published 1952.)
  6. Males T. Telephone consultations in primary care. London: RCGP; 2007.
  7. Pettinari CJ, Jessop L. Your ears become your eyes: managing the absence of visibility in NHS Direct. J Adv Nurs 2001;36:668-75.
  8. Department Health. Standards for better health. London: DH; 2004.
  9. Department of Health.The national quality requirements in the delivery of out-of-hours services. London: DH; 2004.
  10. Royal College of General Practitioners. Out-of-hours clinical audit toolkit. London: RCGP; 2007. Available from: http://www.rcgp.org.uk/quality_/quality_home.aspx
  11. Royal College of Nursing. Telephone advice lines for people with long term conditions. London: RCN; 2006.
  12. Medical Protection Society. Case report “Inappropriate advice” - casebook 13:4. 2005. Available from: http://www.medicalprotection.org/uk
  13. Salvage J. Personal connection is nursing's foundation - even on the phone. Nurs Times 2001;97:2.

Resources
Be careful to use or recommend websites with clinical credibility, such as:

NHS Direct
W: www.nhsdirect.nhs.uk

NHS
W: www.nhs.uk

National Library for Health
W: www.cks.library.nhs.uk

UK Stroke Association
W: www.stroke.org.uk 

Support for those who experience panic attacks
W: www.nopanic.org.uk

ERIC (Education and Resources for Improving Childhood Continence)
W: www.enuresis.org.uk

Cancer Information Charity
W: www.cancerbackup.org.uk