O R I G I N A L

A R T I C L E

The development of
telephone triage:
historical, professional
and personal
perspectives
Elizabeth Breslin and Janice Dennison
The authors examine the concept of nurse led services: professional, theoretical,
developmental, and ethical implications for the nursing profession, patients, and their
families. In the UK, the Scope of Professional Practice (1992) cleared the way for
registered nurses to expand their role, ultimately to provide a better service and to
develop the profession. The nursing profession has a strong tradition of adapting to
change and responding positively to new health care needs (DOH 1999). This nursing
strategy for England makes particular reference to nurse led initiatives and direct
reference to National Health Service (NHS) Direct; the 24-h nurse led telephone help
and advice service available across England and Wales. Particular attention will be
focused on a nurse led telephone triage which was developed in the authors own area of
elective orthopaedics. c 2002 Elsevier Science Ltd. All rights reserved.

Editors comment
Orthopaedic nurses are taking on greater and more varied roles as health care systems develop. Why and how we are
moving in this direction needs constant examination. This article discusses some of the issues relating them to
telephone triage and puts them in context.
PD

KEY WORDS: telephone triage, expanded role, nursing, nurse led

INTRODUCTION

Elizabeth Breslin RGN,

BSc(Hons)
Orthopaedic Course Student,
Sligo General Hospital, Belfast
UK.
Janice Dennison RGN,
BSc(Hons)
Correspondence to:
Janice Dennison
Sligo General Hospital,
Sister Outcomes Team,
Musgrave Park Hospital,
Belfast, BT9 7JB, UK.
E-mail: janice.dennison@
greenpark.n-i.nhs.uk

Health professionals today are constantly facing

challenges to provide a high quality service to
clients, a service that is accountable and evidence
based. In recent years there have been many
changes in the delivery of health care in the
United Kingdom, as a result of health service
reforms (Cattini et al. 1999). In specic areas
nurses are leading services, admitting and discharging patients and making complex clinical
decisions and prescribing programmes of care
(Richley 2000). Nurses continue to identify areas
of independent practice where they are able to
initiate and deliver care and incorporate certain

Journal of Orthopaedic Nursing (2002) 6, 191197 2002 Elsevier Science Ltd. All rights reserved.
doi:10.1016/S1361-3111(02)00070-5

areas of work previously carried out by medical

sta (UKCC 1996).

PROFESSIONAL IMPLICATIONS
Previous to the Scope of Professional Practice
(1992), nurses had extended their role by undertaking certain tasks normally performed by
doctors. Historically nurses were trained to carry
out these extra tasks and the delegating doctor
would ensure competency was reached (DHSS
1997a,1997b). The Scope of Professional Practice
(1992) cleared the way for registered nurses to
expand their scope of practice according to a set

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Journal of Orthopaedic Nursing

of principles. The Scope of Practice (1992) gives

the nursing profession through the grading system an opportunity to develop practice. Nurses
are in a position to oer a seamless, more continuous service meeting patients needs and requirements in a more holistic fashion. This is
very evident in the development of the nurse led
service. Campbell et al. (1999) reported on a
nurse led study in oncology. It identied a holistic service for patients and the ability for the
caregiver to further establish the role of the extended nurse. The implications of the Scope of
Practice (1992) are far reaching for the nursing
profession as it provides an avenue for nurses to
practice in an innovative manner. However,
nurses must be aware of their limitations. The
extended role can leave nurses vulnerable and
pressure must not be placed on individuals to
alter practice without structure and an evidence
based approach. The diversity of the Scope of
Practice must not be overlooked. Fox (1995) saw
the vision of the Scope as a chance to change the
practice boundaries of Nurses, Midwifes and
Health Visitors.
Dowling (1996) examined the role of the
doctor and nurse with emphasis on the role of
the nurse practitioner concluding that nurses are
not seen to be merely substituting the medical
role but adding a new dimension to their care.
Read (1999) notes that the nursing profession
needs to have a strategic approach to role development, and specication at regional and
national level, including education needs and
provision of services. Read (1999) also reports
the need for mutual recognition between medical
and nursing professions and that extending the
nursing role may compromise the caring role.
Dowling (1996) also suggested that proper
regulation must be in place and that the United
Kingdom Central Council (UKCC), now replaced by the Nursing and Midwifery Council
and the General Medical Council (GMC) should
work together with the NHS Executive to ensure
proper regulations and standards are in place.
Dowling (1996) cited professional isolation and
the transition of role development in the nursing
profession as areas to be given careful attention.
Evidence based healthcare has had a major
inuence on the development of the role of the
nurse. Nurses in their extended role and in the
role of expert decision maker must ensure that
evidence based practice structures are in place as
described in The Future of Professional Practice (1994), which considers the role of expert
practitioners and examines education, research
and management skills, due to the perceived lack
of development of professional knowledge, skills
and competency.
The implications from the New Deal for Junior Doctors (NHSME 1991) and the proposals

in the Professional Scope of Practice (1992) has

had a major inuence on the continuing development of the role of the nurse. Pyne (1992)
suggested that professional nursing practice must
be based on both competency and accountability, and should lead to unrestricted, patient
centred practice. Boylan (1992) proposed that
nurses should be free to make autonomous decisions about patient care based on patient need
and the knowledge and skills of the caregiver.
Co-operation and collaboration between professionals is seen as vital if care is to be primarily
in the patients best interest (Rose et al. 1997). In
addition patients perceptions of the extended
autonomous nurse aects whether or not
changes will be accepted as patients are seen as
monitoring and this has the potential to become
litigious (Rose et al. 1997).

THEORETICAL IMPLICATIONS
Nurse led initiatives have always been in existence but since the 1970s have been viewed in
some areas as nursing experts caring for a
particular client group and usually with postqualication education and a research base.
Murray (1999) discussed the changing expectation of patients, carers and professional bodies.
Hancock (1997) took the view that a nurse undertaking new roles to enhance patient care
requires individuals to demonstrate their competence and accept accountability. The UK
Governments White Paper, The New NHS
Modern, Dependable (1997) and A First Class
Service: Quality in the NHS (1998) stated that
quality should be placed at the heart of healthcare. Local trusts should take responsibility for
clinical governance, ensuring that the service
being provided is quality driven and accountable.
Nursing is in a privileged position to carry this
forward as their closeness to patients provides an
avenue to promote and improve standards of
patient care. Clinical audit can be developed and
the concepts of continuing professional development can be achieved through this framework.
Nurse led services are considered to be at the
forefront of nursing development, with the
power to make clinical decisions and prescribe
programmes of care.
Dinsdale (1999) perceives the government as
being supportive of nurse led clinics because of
their impact on waiting times. It is important
that nurses who take on the advanced role do so
with the primary aim of improving the quality of
life for their patients rather that lling a void
which the reduction in junior doctors hours has
initiated (Loftus 2001). Patient and nurse contact
through the review of patients at clinics has increased and the relationship has developed.

The development of telephone triage: historical, professional and personal perspectives 193

Musgrove et al. (1998) report the main objectives

of a nurse led clinic in leg ulceration as holistic
assessment, monitoring healing rates and facilitating compliance. There is also the potential of
improving and building a strong link with the
multidisciplinary team in the hospital and community. Newton (1996) describes the benets of a
nurse led pre-admission clinic for patients undergoing elective orthopaedic surgery. Newton
(1996) reported patients having improved
knowledge regarding their condition, realistic
expectations, minimising the chance of having
surgery cancelled and adequate preparation for
discharge.
Dowling (1996) reported nurses in the nurse
led environment feeling uncertain of their professional identities resulting in a feeling of isolation and not belonging. It was also noted that,
there is a risk of nurses taking on increasingly
greater amounts of technical and medical work,
thus threatening the caring characteristics highly
valued in the nursing profession.

DEVELOPMENT OF NURSE LED

TELEPHONE TRIAGE
As changes are taking place in the UK healthcare
system due to demography, patient expectation
and technology, providers of healthcare are
seeking to improve and establish a better method
of direct patient access (Twomey 2000). Nurse
led telephone triage is a new and controversial
eld of care. Helplines have been a contact point
for many decades in the voluntary support service, ranging from large national organisations
to locally run helplines; these include the Samaritans, and bereavement services. Helplines in
this eld traditionally oer support, advice and
information to the public and deal with many
aspects of contemporary life.
Nurse led telephone triage has the same fundamental principles and is a relatively new
method of patient contact in the UK. It is rapidly
becoming established and expanded in the care
process. In the USA nurse telephone trials systems have shown to be an eective process for
directing patients to the appropriate level of care
without adversely aecting their health (Robinson 1996; Wasson et al. 1992). The Government
has formally acknowledged the use of telephone
helplines as a vital link for the patient and the
professional. NHS Direct is a major Government
initiative, and was launched in response to the
white paper, The New NHS: Modern, Dependable (1998). Initially in 1998 the service was piloted on three sites in the UK. It is a 24-h
telephone helpline led by nurses and accessible
by the entire population in England and Wales.
Specially trained nurses provide information and

advice. This helpline is considered to be the

biggest provider of healthcare in the world.
Robinson (1996) reports the increased use of
telemedicine, but questions the problems and
pitfalls of telephone advice as well as the legal
and ethical implications. In a report by Dun
(2000) on NHS Direct, patient satisfaction is
recorded as being high, and accepting of the type
of system in place. To date close to 4 million calls
have been recorded since the system was established. This in turn will generate a substantial
amount of data relating to the health and well
being of the population and provide a component of strategic planning and evidence based
practice. The overall aim of the system is to
support the Governments vision of providing
easier and faster information for people about
health, illness and the NHS so that individuals
are better able to care for themselves and their
families (DOH 1998).
Dun (2000) in his analysis of NHS Direct
found that there was no evidence to suggest that
the system had reduced Accident and Emergency
attendance. This was a major target in the initial
setting up of this system and will require further
review.
The telephone helpline is fast becoming established in the primary care system with increasing demand on the service. For patients
traditionally a call from the hospital was feared
to be bad news. This concept is changing and
healthcare conducted over the telephone, whether a landline or mobile is becoming established
and accepted. Lattimer et al. (1998) reported on
a randomised-controlled trial to show the safety
and eectiveness of nurse telephone consultation
in out of hours primary care. The trial was carried out over one year in a primary UK healthcare setting. A substantial reduction in General
Practitioners (GPs) workload was noted during
the intervention period. Nurses dealt with half of
the fourteen thousand calls. Patient benets included a reduction in readmission to hospital
and inappropriate readmission. These ndings
have economic implications, both positive and
negative. A criticism of the study design was the
lack of information on long-term outcomes for
the group of patients in order to further examine
the eectiveness of the triage system. Tanna
(1999) recognised this on review of the data and
suggested further investigation would be required. Hallam (1997) found GP and co-operative services had a reduction in the rates of home
visiting, with the provision of a telephone advice
and out of hours care.
In the South Wiltshire Out of Hours Project
(Swoop 1997) it was reported that nurses carrying
out telephone triage was feasible, and patients on
the whole found the telephone triage acceptable.
The demand for advice and information over the

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Journal of Orthopaedic Nursing

telephone is a common but largely an unrecognised area of many health care environments. Accident and emergency departments traditionally
have nursing sta who are highly skilled in providing advice over the telephone. A criticism of
the service is that it is impersonal, not accessible
to everyone and not accepted. Calls in the accident and emergency department are usually answered by nurses who assess patients needs, may
provide advice for self care, prompt the caller to
seek immediate attention or refer the caller to
another health care professional or agency
(Crouch 1996). Telephone nursing has been
demonstrated as eective in a wide range of
clinical settings (Harris et al. 1991; Marklund
et al. 1991). Research by Marklund et al. (1991)
reported that 59% of out of hours calls required
telephone advice alone. However, Hallam (1997)
found in a survey of General Practitioners that
they disliked nurse led telephone helplines as a
form of care, particularly if they did not know the
patient.
Telephone advice by nurses has been shown
to be safe and eective in the healthcare setting
(Dale 1998). Balas et al. (1997) reported healthcare technologies can improve clinical processes
and patient care outcomes, reduce hospital stay
and improve and establish the relationship between the care giver and the receiver. Obviously
extensive thought must go into establishing a
telephone triage system. The sta involved must
be enthusiastic and knowledgeable and aware of
the potential benets and risks. Time is of major
importance when carrying out a planned telephone review, to ensure clarity of information
received and advice given. Condentiality must
by maintained and informed consent obtained.
Information technology departments have
developed systems for telephone triage; such as
NHS Direct where the TAS (Telephone Advice
System) is used. Dun (2000) reports that not
only are the technical aspects of information
technology important but the information it
gives must be timely.
The authors work within an Orthopaedic
Outcomes Team and are responsible for inuencing the care of patients undergoing total knee
and hip replacement. This is a total care system
for patients with nurse led telephone triage focusing highly in the pre- and postoperative period (OBrien et al. 1999). A 24-h telephone
helpline is rmly established with software being
developed in-house to record information related
to the patient. This is a very complex system and
has the facility to correlate data relating to trends
and complications relating to the patients surgery and satisfaction rates. The authors found
within their practice that telephone triage is an
integral part of their work. Patients report feeling safe and comfortable in the knowledge that

there is someone at the end of a telephone who

can oer help and advice. It is considered that
patients within this system have a more holistic
and realistic approach to their programme of
care. They are encouraged to contact the unit if
any problems occur in relation to their surgery.
Telephone triage by specially trained nurses who
prescribe appropriate advice and information
and use appropriate decision making skills
means that the patients condition is assessed and
treatment planned. Education and training is an
essential part of the skills required for health
professionals involved in telephone triage.

ETHICAL AND LEGAL

IMPLICATIONS
Roa (1994) voiced concerns that telephone reviews with patients are too time consuming and
lose vital non-verbal clues. Wooton (1996)
highlighted the positive value of face to face interaction. Telephone conversations can be uncomfortable for some patients and a majority of
patients may feel more relaxed with an outpatient appointment. Telephone triage nurses have
to be able to communicate well, have good
interpersonal skills and be eective in public
relations (Coleman 1997), nurses making decisions regarding patients on the telephone are
drawing on an expert knowledge base derived
from training, experience and further education
(Edwards 1994).
Nurses focus on their intuition to help make
decisions regarding patient care, this can be a
vital component in the decision making process
and is dicult to quantify. Kenny (1994) describes two types of intuitive thinking, cognitive
and empathetic. Kenny described cognitive
thinking as the pooling of information quietly.
Empathetic was described as a feeling. Although the concept of intuition has a role to
play, nurses must always be in a position to
quantify their action in the best interest of the
patient.
There has been specic training material developed to assist in the integration of the telephone into the care setting and is used in the
training of nurses working in NHS Direct. Educational preparation and decision support are
considered essential components in nurse led
telephone advice and triage services. Patients
needs and limitations must also be taken into
account. Dale and Crouch (1997) recognise that
there is no formal training in this area and recommend training in telephone consultation skills
as part of the undergraduate curriculum.
Today a more active questioning approach,
reecting on social change and a greater awareness of health issues have replaced the passive-

The development of telephone triage: historical, professional and personal perspectives 195

accepting role adopted by patients in previous

years. The Government (Department of Health
1999) has not only encouraged but also actively
promoted the widespread use of nurse led telephone triage systems as a way of reducing cost,
time and improving access to healthcare services.
However as with any extended roles there are
legal and ethical implications to consider in relation to the concept of telephone triage. At one
end of the scale there is the belief that no one
should give advice over the telephone and at the
other end there is the belief that specially trained
technicians should give advice with the aid of
computer information (Emergency Nurses Association 1991). According to Young (1989)
nurses are the best professionals to give telephone advice as they are well-trained competent
professionals and the cost of doctor versus nurse
has implications.
Nurses have taken on telephone triage as a
function based on the nursing process (Brennan
1992). This process takes into account assessment, diagnosis, plan information, necessary intervention, and nally evaluation. Care given by
a nurse must be safe, eective, and appropriate.
Telephone triage should be considered as no
dierent from hands on care so the same rules
apply. The international council of nurses state:
A nurse is a person who has completed a programme of basic nursing education and is qualied and authorised in their country to practise
nursing. Therefore, decisions have to be made
about what the trained nurse can be held responsible for. Most telephone triage uses a
symptom based system. A large majority of
nurses will in the course of their role be required
to give a nursing/medical diagnosis. When addressing a medical diagnosis, nurses may well be
contravening their Code of Professional Conduct
(UKCC 1992) and may be practising beyond
their capabilities. Nurses in this role must be
aware they can be legally liable for advice given
to patients.
The use of protocols, documentation of calls,
quality assurance, and audit checks can help
protect telephone triage nurses in the course of
their duty to care. Nurses are human, so there is
always the possibility of error. Protocols,
training, and support are necessary to maintain a
consistent high standard of care over a variety of
conditions. Accountability means the nurse must
make conscientious use of protocols, complete
the correct documentation and adhere to
the standards and quality assurance guidelines.
Autonomy means using an independent
judgement for each call and deciding to override
the protocol if the situation requires and this has
implications for health authorities. Employers
are vicariously liable for the torts of their

employees; therefore, it is in the employers best

interest to ensure that nurses have workable
guidelines within which to practice (Dimond
1990).
Although medical and nursing litigation cases
are growing in this country there have been relatively few malpractice actions (Dimond 1990).
Castledine (2001) reported a case which resulted
in a professional conduct hearing following the
death of a 7-year-old boy after his mother had
been diverted to the triage system where the
nurse oered advice. The nurse appeared before
a professional misconduct committee. Allegations against the nurse were that she failed to
keep a contemporaneous record of her contact
with the boys mother and that she accepted inappropriately delegated tasks from doctors. Record keeping is an integral part of nursing,
midwifery and health visiting practice. It is a tool
of professional practice and one that should help
the care process and it is not an optional extra to
be tted in if circumstances allow (UKCC
Guidelines for records and record keeping 1998).
The nurse in this case was found guilty of misconduct but not removed from the register. The
case highlights the integral and complex area of
telephone triage for nurses practising in the best
interests of patients and their carers. If nurses are
more condent in their legal knowledge of the
rights of the patient and there own duty, then
they will full their professional duty under the
Code of Professional Conduct (1992).

DISCUSSION
Nurse led services are a challenging aspect of the
extended role of the nurse. The use of the telephone for patient contact has shown to be successful and has the potential to become further
advanced. The publication of The Scope of
Professional Practice (1992) and the reduction of
junior doctors hours has had a far-reaching effect on the nursing profession. Section (9) of The
Scope of Professional Practice (1992) allows
nurses to expand their activity in nursing undertaking responsibility for a nurse led service.
The practitioner must acknowledge limitations,
thus ensuring the patients best interest is protected. Eective communication is a necessary
component in this process; nurses must be able
to justify their actions clearly and continue to
build on their knowledge and skills. Practitioners
base their decision-making skills on quantitative
and qualitative data obtained from the telephone
call. Skills are established and advance through
training, experience, knowledge and intuition.
Telephone triage is a service that will continue
to grow and public enthusiasm is encouraging at
a national and local level. Telephone healthcare

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Journal of Orthopaedic Nursing

is rmly wedded to strategic planning. This has

implications for practice regarding training and
development, the possibility of incorporating this
type of training into the basic nurse training,
thus preparing for the future in this fast advancing world of telemedicine.
Further evaluation of the method is required,
with particular attention to those sections of the
population excluded by diculty in accessing or
using the telephone. Telephone triage must be
practised carefully in order to meet the needs of
individuals. Nurse led support appears to be a
legitimate use of nursing time, providing it does
what it sets out to do, supporting, helping, educating, and informing patients (Dale and Crouch
1997).

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