NHS Direct: examining the challenges for nursing practice

An evaluation of the appropriateness of advice and healthcare contacts made following calls to NHS Direct Wales

Background

An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here.

Methods

Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received.

Results

Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs.

More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%).

Conclusion

Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

Quality monitoring of nurse telephone triage: pilot study

BACKGROUND

Nurse telephone triage is a popular way of managing workload in primary care and has been shown to be as safe as general practitioner (GP)-delivered alternatives. No studies have tested a routine method of assessing the quality of decision-making by triage nurses in primary care.

AIMS

The aim of this paper is to describe a study to evaluate accuracy and utility of audiotaping telephone consultations to assess the quality of decisions made by practice nurses triaging same day appointment requests in routine practice.

METHOD

An observational study was carried out using external assessment by GPs and nurse practitioners of triage quality in 218 audiotaped nurse telephone triage consultations.

RESULTS

There were high levels of agreement between triage nurses and assessors on identifying the presenting problem. However, there were only moderate levels of agreement between GPs and nurse assessors both on level of information sought (kappa = 0.434) and appropriateness of outcome (kappa = 0.614). Assessors rated information-gathering as poor in 19.3% of calls (95% confidence interval 14.6 to 25.0), and seven (3.2%) consultations were rated as potentially dangerous (95% confidence interval 1.6 to 6.5). A 1% sample of all consultations would have a probability of 0.48 of identifying unsafe consultations and 0.99 probability of identifying consultations with poor information-gathering.

CONCLUSIONS

External assessment of triage quality may be of only moderate accuracy and reliability. Nonetheless, considerable information can be gleaned from assessing audiotapes to assess consultation quality. Even where nurses are generally highly skilled and competent, a 1% review of triage consultations would be sufficient to identify their information-gathering learning needs in relation to patients' presenting problems. Audio-taped consultations could be an important part of clinical governance strategies.

Telephone nurses' experience of problems with telephone advice in Sweden

By telephoning a healthcare call centre, individuals in Sweden can consult a nurse to discuss medical problems and health care accessibility, and to receive professional information on how to find their way about the health care system. The aim of the study was to identify problems, difficulties and disadvantages that telephone nurses with varying degrees of experience had met during their professional careers. The Delphi technique was used with three sets of questionnaires. Twenty-five nurses with varying experience of working with telephone advice from six 24-hours call centres participated in the study. The response rate was 100%. An open-ended question generated 154 statements. Comments were categorized into 24 different problem categories. Ten problem categories were mainly related to the nurse perspective, i.e. the problems experienced were associated with the qualities of the nurse, eight principally to the patient perspective, i.e. problems associated with caller characteristics and six mostly to the organizational perspective, i.e. problems linked to the organization of the national health service. 'Lack of health care resources' was rated as the biggest problem, 'second-hand consultations' as the second and 'always making a decision' as the third biggest problem. Decision-making seems to be the core of telephone advice nursing and problems related to the nurses, patients and organization seem to influence the telephone nurses' working situation. Training should focus on active listening and handling social conflicts.

NHS Direct: issues for education, management and research

The NHS Plan (Department of Health (DoH), 2000) specifically highlights the role of NHS Direct in its vision of a health service designed around the patient. Despite this, the new nurse-led service has come under critical attack. NHS Direct is in the process of developing an evidence base to underpin its practice. It is recognized that telephone management skills are important clinical skills and while decision support computer software can help elicit an appropriate client history, the interpersonal skills necessary to establish a professional telephone relationship are commensurate with the suitability of the appropriate education programme. This article will explore the ramifications of NHS Direct for curriculum development and evaluation. Factors such as skill mix, career pathways, recruitment and research and development will also be discussed. In a previous article the implications of NHS Direct for practice were examined (Glasper et al, 2000).