Telephone triage: Assessing the priority and need for assistance and advice

This guide for nurses general practitioners and anyone who might consult on the telephone describes the essential ingredients in managing the process. Because the guide is primarily aimed at GPs working out of hours, the analogies chosen often refer to 'Dr' X. However, there will be a great resonance felt by practice nurses and many other clinicians who have to consult on the telephone and the text can form a useful basis for discussion between different cilnical groups.

The call management techniques that help communication and make for a good outcome for clinician and patient are described. The guide draws together some of the best of NHS Direct communication skills with work from Andy Hill, Mental Health Site Lead at NHS Direct North East, and the successfully developed triage processes used in a large GP Co-op (Northern Doctors Urgent Care), with work from Dr Kevin McKenna and Dr Patrick Feeney.

How we see ourselves is very important in triage. A poor negotiator is poor at triage. Poor triage technique is often a marker for broader difficulties in consultation processes that make for patient misunderstandings and stress for clinicians. A good triage technique needs the clinician to be comfortable with themselves, alert but not anxious and prepared to negotiate. Some of us have personalities which make triage intrinsically easy or difficult. All of us can learn to do it better and feel more comfortable in the process. Firstly you need to identify your personal rights, wants, and needs. Respect for others in negotiation begins with self respect. To achieve control of the call it is vital that you are assertive without being domineering. Before looking at the triage process itself it is important to look at ourselves and how we relate to others. Are we assertive or aggressive? Do we avoid issues rather than tackling them?

Assertiveness 

Expressing thoughts, ideas and feelings in a way that doesn't threaten or punish other people is very important. We are assertive when we act without showing fear or anxiety but without violating the rights of others. When we are assertive rather than aggressive we are able to negotiate. Because we generate feelings of respect for others they will be more willing to co-operate in discussions. They and we feel comfortable.

An assertive individual listens, negotiates and effectively influences other people. An aggressive person suborns and dominates (Hitler was not a negotiator!). They put their wants and needs above those of others. They do not offer choices but would seek to win. They may enhance their position at the expense of putting down or humiliating others.

While we all recognise aggression and will feel uncomfortable especially when it is directed towards us, we wili often feel comfortable in the presence of assertive people.

People who are non-assertive in their lives are often very comfortable to be with as they avoid conflict but they often do so at the expense of their own needs. This often communicates as the message of inferiority and may cast the person in the role of the victim.

How does this relate to our activity on the telephone?

Non-Assertiveness 

Non-assertive behaviour is passive and indirect. It permits others to violate our rights and shows a lack of respect for our own needs. It communicates a message of inferiority. It creates a lose-win situation because the non-assertive person has decided that his or own needs are secondary and opts to be a 'victim'. Mrs Wimp (Receptionist) "You want an appointment to talk about your holiday? We haven't got any Mrs Stalin but I'll put you in as an extra with Dr Spineless". Later that day - Dr Spineless, "Oh, I should talk to Mrs Wimp, she hasn't a clue but she'll only get upset if I do. She didn't speak for two weeks the last time I mentioned anything".

If a person feels unable to communicate directly with another they may 'bottle feelings up', which spill over into subsequent interactions. This can lead to a build up of tension that can become destructive. Dr Spineless will grumble and Mrs Wimp will probably know of his frustration - a row brews!

Aggression 

Aggression is easily identified in ourselves and others in the voice-tone, volume and pitch. It makes the listener uncomfortable, anxious and makes them aggressive in turn.

Directly aggressive speech: 

Indirectly aggressive speech: 

By comparison passive speech is also readily identified.

Passive speech: 

When we are assertive, the characteristics are also clearly apparent. 

Assertive speech: 

Having looked at different speech patterns, what are the basic strategies for behaving assertively and effectively?

Firstly you need to identify ~ personal rights, wants, and needs. Respect for others in negotiation begins with self respect.

You have a:

Armed with our 'bill of rights' we are ready to pick up the phone!

Triage 

To sift sort and classify material so that it can be dealt with according to priority

In a telephone consultation setting you need to do this using communication skills that involve only speech and hearing, there are no visual clues. The essentials seem so obvious, how can it go wrong? More importantly, how can we prevent it from going wrong?

The whole process is broken down in detail but the key parts of a good triage are: 

There are several identifiable stages of a phone consultation, or triage just as there are in face-to-face contact.

1

The introductions

Always introduce yourself by name and ideally mention your organisation. If the caller is not the patient, establish/confirm the identity of the caller and relationship to the patient (and consider any implications for confidentiality).

Try to speak directly to the patient if possible/appropriate. A first hand history tends to be more reliable although there are clearly situations when an additional history from a third party will be valuable.

Always empathise as few patients, no matter how offhand they seem, take the decision to call lightly. An initially prickly, demanding manner may be fuelled by anxiety, so empathise when you take the call, e.g.: "I hear (x) has a nasty sore throat, tell me all about it".

Clinicians should remember that if it is the second call for the same patient within a short time frame, it will often require an even more careful and thorough triage as statistically it is more likely to indicate a more significant clinical problem which requires a face to face consultation.

2

Gathering information

Listen to the caller and give enough time to place yourself in a position to assess what they are saying. Allow the caller to give their own account of the problem in their own words with the minimum of interruptions. When someone is ringing up with a clinical problem and you are trying to obtain information, the five 'W's are useful guides:
  • What is the problem? 
  • Where does the problem occur? 
  • When does the problem happen? 
  • What makes the problem better or worse? 
  • What is the timeframe for the problem?

Armed with this information you have the necessary data to enable the problem to be addressed.

There are certain predictable errors that occur when asking questions:

  1. A longwinded build-up (Dr Boring) 
  2. Multiple choices that are two numerous and come too fast for the person who is listening to you ("Have you could tried 1 ... 2... 3.. .4... .5... .6.... or did you...?)
  3. NHS jargon that might be confusing ("Pyrexia is tricky in kids under 2, was it a grand mal seizure he had...?)

Asking questions and getting the right answers is not always easy! 

How we ask the questions may help or hinder the caller from giving us what we need to know. There are two types of question, open and closed questions. Open questions can never be answered with a yes or no e.g.

  • "How are you?"
  • "What happens next?"

Closed questions on the other hand can easily be answered with a yes or no e.g

  • "Do you have a headache?"
  • "Did you check the time?"

If you are trying to get the person on the other end of the phone to talk more you need to use open questions e.g.

  • "You sound upset, how long would you say you have been like this?"

It is important to engender the confidence of the caller by making it clear that you are interested in what they are saying. It is equally important to avoid any unnecessary questions that might be regarded as an invasion of privacy or make the conversation sound like a police interrogation! Try to deal with issues one at a time.

While it is important that you are in charge of the call it is vital that the caller is not made to feel in a vulnerable position. Avoid poorly timed questions and try hard to avoid repetition as this diminishes the confidence of the caller. Deliver questions/information in a clear manner, without 'waffling or padding' or 'beating about the bush'.

Consider whether enough information has been gathered to allow a safe assessment of the problem and a safe management decision and crucially, have all conditions requiring more urgent action been reasonably excluded?

It is always important to be sure you have established the "caller's agenda". Sometimes the caller/patient's ideas, concerns and feelings become evident without more direct questioning. Sometimes you will have to ask, e.g. "Tell me, have you any worries about what might be going to happen" or "have you had any bad experiences with these sort of symptoms before? ". Then, the fear of the throat closing up, the ear drum perforating or meningitis developing will be out in the open.

Always try to maintain respect for the other person and avoid labelling "Typical behaviour - they're all the same ". Without respect, negotiation is impossible.

Sometimes you can help the caller who is anxious or angry with the use of "I" Statements. Using 'I' Statements allows a person to 'own' their thoughts feelings and opinions rather than using 'you' Statements, which may implicitly blame the other person.

I' Statements may be used:

  • Anytime you want to share your feelings in a frank, unthreatening, undemanding way
  • If both parties have issues to resolve
  • If the caller uses 'you' or blaming statements a lot. Remember your 'rights' must not be violated

I Phrases can make repeated or sensitive questions or statements less threatening. 

  • "I am wondering...." 
  • "I get the feeling that..."
  • "I have a sense of..."

'I' Statements can be used to diffuse hostility:

  • "I understand that you are angry" 
  • "I am sorry that...." Can be an expression of sympathy only and does not have to imply that anything was your fault

'I' Statements that disclose your feelings in a professional manner and create empathy:

  • "I am concerned that"

Having drawn together the information we need to assess the situation a management plan can be devised.

3

The action plan

Make sure the other person is listening. In any plan involving two people there is a negotiation necessary. You are looking for win/win as the ideal outcome. You may however, be dealing with someone who wants you to lose. If you feel this is the case, how do you tackle the situation?

You may need to use 'Broken Record' for this purpose before you move onto your main message:

  • "We'll come back to that later. I'd like you to listen to me" 
  • "I don't think you have heard what I said, I'd like you to listen"

'The broken record approach'

The Goal:

To be very clear about what you want to say and to make this known without getting angry, uncomfortably irritated or loud. 

When it's Useful:

In conflict situations, when refusing unreasonable requests, when saying no, when asking questions for clarification, when being taken advantage of and when expressing requests especially when the other person isn't listening.

What you do:

You speak as if you were a broken record. You need to be persistent, to stick to the point of what you want to say, and just keep saying what you want to say over and over again. It is very important to ignore all the side issues. Do not be deterred by or respond to anything, which is off the point you are trying to make. Just keep saying in a calm and repetitive voice what you want to say until the other person hears what you are saying. Broken records eventually get heard. It is uncomfortable to listen for too long!

When a decision is made the following main outcomes are the result:

Information or advice only is required

Share your thinking with the caller, i.e. "this sounds highly likely to be a nasty virus" or "if it was something that I need to see immediately, such and such would be happening". When giving advice, as with asking questions, be assertive but not aggressive. "It would be good to give paracetamol on a four hourly basis because " rather than "I told you before, tepid bathing went out years ago

Always check that there is agreement and understanding of what you propose. This is important. It might also be necessary to emphasise your confidence in your own advice e.g. "yes, I'm sure this is medically sensible and safe, could we try it for a while". "Are you happy with that?" etc.

Being able to help is wonderful but it is important to stress, where necessary, what you are unable to do so that the caller does not have unrealistic expectations. E.g. "I cannot arrange an outpatient appointment any more quickly than your own clinician but I am happy to listen and see if there is anything I can offer...."

A face to face consultation with a GP is necessary

This may be either at a centre or at home. Well established models exist for establishing the venue for a face to face consultation. The Staffordshire criteria or the NDUC/ NHS Direct North East visiting algorithm (Appendix 1) clearly define the letter of the law.

This is an area where assertive negotiation may be required to establish a genuine win/win relationship with the caller. Be prepared to work together towards a compromise without neglecting yourself or your beliefs (a win-win situation). "If we can meet at the Primary Care Centre I will be able to see you more quickly". Think positively and do not presume a negative outcome will occur. "I don't suppose you can bring him in, you see I'm very busy" is less likely to engender the response you are seeking. Such statements tend to be self-fulfilling!

A consultation with others is needed (999 Ambulance, Nurse referral, social services)

It is important that the caller fully understands why this course of action is being taken and that they agree decision. If the agenda is agreed the clinician will have reassured the patient that the best action is being taken. If not, the patient may be made even more anxious and refuse the ambulance when it arrives. 

4

Concluding the call

During the course of the call you have identified the key elements to enable you or a colleague to resolve the caller's situation. In terminating the call it is important that the outcome of the call is agreed between both parties. In this way the caller will feel confident that an appropriate outcome will be achieved and will not have unrealistic expectations. This might be expressed as:

"Just to recap, we've agreed that you will try to use the calpol on a four hourly basis and check his temperature each hour. If it is settling you will take him to the Health Visitor tomorrow but if not, you will ring back and I will see him at the Primary Care Centre before 11 o'clock. Are you happy with those arrangements

Always prepare a safety net and give the caller permission to ring back if things get significantly worse, e.g. "please do feel free to call if he gets worse". Give concrete examples of worrying signs and symptoms. Explain what to do if your plan is not working, including when and how to seek help.

Give clear, specific, follow up instructions e.g. "If the pain/temperature has not settled in an hour please call back"

If necessary, re-check patient understanding and acceptance of your plan.

In completing the safety net, remember you may need one too! If possible, allow some time for reflection and if not entirely happy with any element of the triage, never be afraid to phone the patient again.

When a home visit is advised, a (realistic) estimate of the expected time of arrival (ETA) of the visiting clinician is greatly appreciated by patients and carers and in closing the conversation, it is often helpful to end with an expression of "hope it goes well" or "I hope he is better in the morning" etc.

Patient education should always be considered if appropriate. For instance, if someone has rung up about an hour's worth of sore throat it may be reasonable to politely say e.g. "Next time this happens you will know how to cope until your surgery is open, won't you?".

Despite routine recording of most telephone triages, adequate note keeping is still vital. Notes need not be voluminous but they should be legible. In those rare instances of complaint, "contemporaneous written notes" are extremely helpful.

Just as clear management plan is essential for those looking after patients, it is vital for patient confidence that they share an understanding of the plan. The aggressive and usually anxious patient can make life a misery if badly handled. Even these calls can lead to a rewarding consultation if appropriately completed. A confident assertive clinician delivering good advice makes everyone feel better! With clear understanding of the patients' agenda and assertive triage, comes less stress, fewer complaints and a more pleasant working environment for everyone.

More on telephone triage

Telephone consultations