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Telephone triage: the good, the bad and the ugly

Sally-Anne Pygall
Company Director
Telephone Consultation Services

I believe I am now one of the leading authorities on telephone triage work in the country. That may sound arrogant but it's not; because how many nurses do you know who can train telephone triage skills to nurses or doctors and can quality assure telephone consultations for safety and effectiveness, because that's all they've done for almost 12 years?

Is this type of training really needed? Well, I can guarantee that almost every nurse in primary care talks to patients on the phone on a regular basis; usually to give them some form of "advice". First, the nurse will ask a few questions to find out what's needed – they are now doing telephone triage but don't recognise that this is the case and most haven't been trained to do it!

If a nurse is asked to run a surgery's diabetic clinic without training, they would refuse if they didn't have the skills to do it; and yet so many nurses engage in telephone work (commonly to triage home visit requests for instance) without any form of training. In the current flu pandemic, nurses are being drafted into telephone triage to help manage demand for appointments, but without knowing how to do this safely, competently and with confidence, many patients continue to be seen unnecessarily or more worryingly, are being denied care.

The Nursing and Midwifery Council (NMC) states that "you must have the knowledge and skills for safe and effective practice when working without direct supervision". The new NMC record-keeping guidance says, "The principles of good record-keeping apply to all types of records, regardless of how they are held. These can include … tape-recordings of telephone conversations."1,2 It's pleasing to note that the NMC is beginning to realise the importance of telephone work and have included this in their guidance, but telephone triage is usually unsupervised and how do you develop the skills without at least a modicum of training or quality assurance?

Coleman (1997) suggested three ways to protect nurses doing telephone triage from legal liability:

  • The use of protocols.
  • Documentation of calls.
  • Quality assurance and audit checks.3

In my experience, documentation alone can be poor, but most nurses work without basic protocols and few are actively audited for quality. Giving care over the phone carries enormous risks, which can be minimised by
training and awareness of what you need to consider in order to protect you and your patients.

Telephone triage is hugely underestimated, undervalued, underperformed and undermonitored. When it is done well, it can save lives and thousands of pounds in unnecessary face-to-face consultations or visits to A&E. Many patients are seen not because of clinical need but because access is available – thereby perpetuating the culture of demand.
Nurses have been shown to take more time than GPs on the phone but their time is used more effectively because they engage in patient education and building a rapport, therefore empowering patients to look after their own healthcare until such time as they really need to be seen.  

For most clinicians, including GPs, training on telephone triage is not part of their curriculum. Out of hours, there is a national quality requirement that states that each clinician's work should be audited, but there is no stipulation on how this is done.4 Audit of calls "in hours" is particularly rare, mainly because there aren't any Quality and Outcomes Frameworks associated with telephone triage work and it's not recognised as a skill set in its own right.

We have to stop this culture and make sure nurses are given the right training by the right people in the first instance, and supported by the right tools and resources in the second. Only then will patients be cared for safely and appropriately. l

1. Nursing and Midwifery Council (NMC). The Code - Standards of conduct, performance and ethics for nurses and midwives. London:
NMC; 2008.
2. Nursing and Midwifery Council (NMC). Record-keeping: guidance for nurses and midwives. London:
NMC; 2009.
3. Coleman A. Where do I stand? Legal implications of telephone triage. J Clin Nurs 1997;6(3):227–31.
4. Department of Health (DH). National Quality Requirements in the Delivery of Out-of-Hours Services. London: DH; 2006.

For more information please contact:
Sally-Anne Pygall on (0191) 520 8307/07533 072 621 or email: