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Health visitors’ experiences of conducting non-visual assessment of unwell pre-school children via the health visiting duty telephone service: an exploratory qualitative study

19 March 2021

Debbie Outram and Lesley Dibley asked health visitors to rate the effectiveness of the telephone triage processes they follow, focusing on the heightened risk of an unsuccessful outcome and how that may influence their attitude to the task.

Authors:

Debbie Outram, senior health visiting practitioner, Kent Community Health NHS Foundation Trust.

Dr Lesley Dibley, reader in nursing research and education, University of Greenwich.


Research summary

  • The inability to observe an unwell pre-school child presents a challenge for any health practitioner whose only means of assessing its health is to talk to its parents on the phone. Among other things, the task requires advanced listening skills and sensitivity to the caller, who may not be able to communicate effectively.
  • HVs who staff the health visiting duty telephone service find the job particularly difficult because they routinely receive no training in how to provide it. They also have no definitive telephone triage process to follow. Having to work with such limited support tends to increase their anxiety levels and reduce their confidence in their ability to achieve successful outcomes.
  • The study interviewed 14 HVs of varying levels of experience at one health trust about their attitudes to the task of conducting telephone triage and how they had adapted to cope with its demands. 
  • The findings underlined HVs’ concerns about the risks presented by their inability to observe not only the child, but also its parents and family environment. All interviewees expressed their anxiety about their lack of training in telephone triage. One said that they had been ‘terrified’ at having to work solo with no tuition on their first day in the job. Another admitted that they had a ‘really low threshold for referring to a GP’. A risk-minimising action of this type risks wasting scarce NHS resources. 
  • Some HVs reported adopting a systematic approach to telephone triage, following procedures such as the sepsis guidelines set out in ‘the red book’, while others revealed that they were far less structured in their methods. Those in the latter group tended to feel more stressed about the risk of missing a vital cue.
  • When asked what would improve the situation, the interviewees suggested a number of measures. These included: updating the standard operating procedure for duty HVs to cover the management of sick children; routinely recording calls for training purposes; and establishing a clear telephone triage process that would safeguard both staff and clients.
  • One of the study’s main recommendations is that clinical decision software is provided for HVs staffing telephone triage services. This would guide them through specific algorithms to help them assess the situation; support their knowledge, expertise and critical thinking; and offer recommendations on the course of action.
  • The other key recommendation arising from the research is that the triaging of children who are clinically unwell by HVs should cease. Their parents should instead be directed to the NHS 111 service.

Introduction

This research focused on the experiences of health visitors who handle queries from parents of ill children while undertaking the duty HV telephone triage role. The role makes some practitioners apprehensive because of the absence of visual cues and the need to confirm that a comprehensive assessment has been attained for a successful triage outcome. This has led a number of HVs to question their ability to handle duty calls effectively. Those undertaking this task only have the help of a standard operating procedure, which provides limited direction for the management of telephone enquiries (NHS trust, name withheld, 2016). 

A lack of observable cues and the problems that some callers have in communicating relevant information causes some HVs to feel hesitant in their decision-making (Eriksson et al, 2020). It is known that receiving such calls provokes a number of feelings, including uncertainty, anxiety and inadequacy (Eriksson et al, 2019). HVs have reported feeling personally accountable and have expressed anxiety about their responsibility for triage outcomes. Such feelings have led to the adoption of risk-minimising actions to manage uncertainty – an approach identified years ago (Murdoch et al, 2015). 

Nurses develop the skills to assess visually during their initial training. The confidence to use those skills over the telephone comes with repeated experiences of visual confirmation (Wilson and Williams, 2000). A health concern can be simplified through the use of mental representations, which allows for the problem to be interpreted in context (Mackway-Jones et al, 2014). Mental representations can be classified into two groups: the pathology and the person. The data educed from the patient helps the nurse to visualise the pathology, which enables them to use a form of deductive reasoning to determine the problem. By visualising the caller and their context, the nurse attempts to establish what the patient is like to gain a greater understanding of their condition (Edwards, 1998).

As well as using advanced listening and communication skills, building rapport and trust by displaying sensitivity to the caller has been identified as an important factor in telephone assessments (Nauright et al, 1999). Eliciting information from the patient early in the conversation helps the nurse to form a hypothesis of the problem (Purc-Stephenson and Thrasher, 2010). Several participants in one study identified that some callers lack the capacity to communicate significant information and may embellish or underestimate their problem, which potentially reduces their reliability (Wilson and Williams, 2000). Nurses must therefore use a number of detailed or rephrased questions to mitigate such risks (Eriksson et al, 2019). Holmström and Höglund (2007) suggest that distressed callers may provide less reliable descriptions of their condition. Wahlberg et al (2005) surmise that another key element in a telephone encounter is the patient’s vocal behaviour. They advise that the caller’s tone of voice can further enhance the nurse’s mental image of the situation. 

A key focus for the health visiting service is to address six high-impact areas that are known to have a significant bearing on the wellbeing of children and their families (Public Health England, 2017). These are as follows: ‘transition to parenthood; maternal mental health; breastfeeding; healthy weight; healthy two-year-olds and school readiness; and managing minor illness and accident prevention’. It is in this last area that the telephone duty role has a potentially important impact. 

The increasing attendance of pre-school children with minor illnesses at A&E departments is a concern (Institute of Health Visiting, 2019; Holden et al, 2017; Rowe et al, 2015). The limited availability of health services outside hospital, coupled with parental expectations, poor health literacy and a lack of confidence in managing minor illnesses are all factors that increase demand on A&E services. 

There are understandable reasons why parents take their children to urgent care centres. A perceived serious illness will motivate them to do so for reassurance instead of selecting a more appropriate service, for instance (Holden et al, 2017). They perceive A&E as the default option, as it is accessible and dependable in fulfilling their needs for expert medical assessment, care and reassurance (Rowe et al, 2015). If emergency attendances for minor illnesses are to be reduced, parents need to be equipped with the necessary skills to manage their children’s non-critical illnesses at home – and more effective triage services need to be implemented.


The study 

Methodology

An exploratory qualitative approach was used (Stebbins, 2001). This methodology is situated in the interpretivist, post-positivist paradigm. It is ideal for the first exploration of a novel topic or where there is minimal qualitative insight into an otherwise well-researched topic. No specific theory was applied, as the study investigated the meaning from the perspective of the research participants for a comprehensive description of the phenomena (Creswell and Creswell, 2018). 

Aims

The research had the following two aims: to critically explore the experiences of HVs in a primary healthcare setting who handle calls via the telephone triage system from parents with unwell children; and to determine whether a more robust infrastructure and comprehensive telephone triage skills training are required to guarantee quality of assessment and to reduce practitioners’ concerns about the role. 

To achieve these aims, the research question was: ‘Can HVs’ ears become their eyes when responding to parent queries regarding pre-school children who are unwell via the health visiting duty telephone service?’ The project was completed by the lead author for her MSc advanced practice qualification, supervised by the second author.


Methods

Sampling and recruitment 

Purposive sampling was used to ensure that participants had sufficient experience of the issue of interest. The target sample size was 20, which reflects the intention of qualitative research to collect rich, descriptive data that can add to the understanding of an issue rather than to demonstrate measurable facts. To reduce the risk of coercion owing to the fact that the lead author worked in the same NHS trust where participants were being recruited, HVs were notified about the study via weekly adverts included in the bulletins emailed to all HVs in the organisation. Each HV who showed an interest was emailed a participant information sheet and given the opportunity to ask questions. This allowed prospective participants to be fully informed of the study’s intention, methods, benefits and risks before deciding whether to proceed or not. 

Inclusion/exclusion criteria


Ethical approval and consent

Ethical approval was received on 15 November 2019.

Immediately before each interview, the participant information sheet was read through again and a paper copy provided to the interviewee. Voluntary written consent was obtained and each participant was informed that any issues of practice requiring improvement would be addressed if they should arise during the interview. 


Data collection

Interviews were conducted between 13 December 2019 and 13 March 2020. Semi-structured individual interviews, conducted using the interview topic guide (table 2), took place either face to face or over the telephone. These were recorded on a digital audio recorder. Audio files were uploaded to a secure server and transcribed and anonymised by the first author, then shared with the second author for contribution to the analysis.

Interview questions


Data analysis

The data was examined using pragmatic thematic analysis. This involved labelling, organising and interpreting it in relation to a set of themes, so that meanings could be formulated. An anonymised code was applied to each transcription. Five transcripts were shared with the second author. Both authors independently identified issues of interest in the data before meeting online to discuss and verify emerging themes. The first author completed the final stages of the analysis: refining, revisiting and confirming themes.


Results

Fourteen participants were interviewed, 12 face to face and two on the telephone. The self-selected participants were all HVs who were responsible for managing telephone calls to the service. 

Three main themes, each addressing related topics, were identified from the data (figure 1): ‘Lack of visualisation’, ‘Approach to assessment’ and ‘Service provision’.

Figure 1: thematic map: themes and sub-themes emerging from the qualitative analysis

The themes are presented below, supported by interview extracts. Each interviewee is represented numerically, by band and by years in post – for instance, HV6.B6.2.

Lack of visualisation

A consistent issue raised by the participants concerned their inability to see the child, which affected their assessment as a result: 

‘If I’m speaking with a client, I’m not having a visual observation of that child clinically… It is quite difficult to do an assessment.’ (HV6.B6.2)

A commonly held view was that face-to-face contact would be advantageous in understanding factors such as the child’s developmental needs, the caller’s parenting capacity and the quality of the family environment.

‘We are not… able to see the attachment, the care, the handling and the responsiveness of the parent in that phone call – not to mention the environment that the family are sitting in.’ (HV12.B7.10)

Approach to assessment

The findings identified that the participants took one of two distinct approaches to assessment: systematic or informal. Several participants reported that they had devised their own logical methods:

‘I tend to do a top-to-toe – “If you touch, do they feel hot? Have you had need to do their temperature? Are they alert?” – assessment, because then you find you’re less likely to miss out on anything.’ (HV2.B6.4)

The use of the sepsis guidelines in the Personal child health record (known colloquially as ‘the red book’) to aid the triage process was helpful to some interviewees: 

‘I use the sepsis and serious illness guidelines in the red book… It takes you through every single area that you should be asking.’ (HV3.B7.20)

But others seemed to use no structured approach:

‘We don’t have any template about what to ask. It is purely just talking through… depending what the issues are. I could be missing things very easily.’ (HV8.B6.14)

A commonly held view was that the triage role caused participants to feel anxious and unsure:

‘Every time I go on to duty [there’s] a bit of anxiety of what’s going to come up. Am I going to cope? Am I going to know the answers?’ (HV8.B6.14)

A systematic approach helped one participant to manage her lack of confidence and feelings of vulnerability:

‘I’m not confident about it at all… The way I can protect myself is by using… evidence-based sepsis guidelines in the red book.’ (HV3.B7.20)

All participants recognised their limitations:

‘If I felt that vulnerable… I would definitely signpost them to the general practitioner.’ (HV5.B7.30)

Ways to manage vulnerability and anxiety were explored. Most participants reported that they were able to handle their concerns with support, as exemplified here:

‘Doing duty with a colleague is really helpful… [offering me] an additional practitioner view. There will be certain… clinical assessments that I probably haven’t done in my professional career [where I] value a colleague’s input.’ (HV1.B6.6)

An unexpected revelation concerned the inappropriate use of the GP service:

‘I always have a really low threshold for referring into the GP if I can’t see a family face to face… I will find a reason to go to the GP.’ (HV3.B7.20)

Service provision

The participants consistently expressed concerns about their lack of telephone triage training: 

‘[I’ve had] no formal training. We were very short-staffed when I started and I literally sat on my own on the first day, terrified.’ (HV9.B6.15)

An overriding view was that the standard operating procedure for duty HVs failed to support them when they were triaging children:

‘The current duty policy… doesn’t say anything about managing sick children. It needs updating and needs to be more comprehensive.’ (HV3.B7.20)

More commonly, the HVs considered that calls into the duty line should be recorded to assure quality. One participant, who’d had experience of telephone triage in a different role, explained:

‘It’s for verification, but we used to have all of our calls recorded in NHS Direct… They would use it for… training and they would also use it to check someone’s critical thinking.’ (HV11.B6.19)

The importance of having a clear process to safeguard both staff and clients was also frequently suggested:

‘Look at something like NHS 111. They’ve got really clear algorithms about what if someone phones up with X, Y, Z – exactly all the things they have to cover… to keep the clients and themselves safe.’ (HV3.B7.20)


Discussion

The main skills used by HVs include ‘highly developed interpersonal skills, empathy, application of knowledge and observation’ (Cowley et al, 2013). Observation is therefore a critical factor in the assessment process to ascertain the severity of a child’s illness. The child’s appearance, their reactions to their surroundings and their interactions with carers can also be assessed, providing a clearer picture of the problem, the child’s developmental attainment and the parent’s capability to manage the illness (Fernandez et al, 2017). 

The HV’s assessment of a child’s health is a complex, collaborative and continuous process that is not based on a single telephone encounter (Appleton and Cowley, 2008). Illness, particularly among pre-school children, is often evidenced by changes in behaviour. For instance, when a child becomes quieter and more compliant, this can be a more important indicator than the emerging symptoms of the severity of their condition. An HV’s inability to see the child takes away a core component of the assessment. 

Mental representations were commonly used by participants to simplify a child’s health needs (Mackway-Jones et al, 2014; Edwards, 1998). Other strategies included the use of interpersonal skills to extract detail from callers. The success of this approach varies according to the capability of the caller and/or the competence of the call handler (Pettinari and Jessopp, 2001; Wilson and Williams, 2000). 

‘The skill of the consultation and ability to get the essential information on which to make a decision rest on the packaging of the questions.’ (Monaghan et al, 2003). It is therefore imperative that the handler has the necessary communication skills and strategies to make an accurate assessment.
Owing to the varying professional backgrounds of HVs, another common telephone triage approach was to seek the support of colleagues, which was valued in reducing concern and vulnerability. Without collegial backing, the performance of call handlers and the quality of care delivered may be affected (Wahlberg and Björkman, 2018). 

The findings of this research revealed that the assessment process could be conducted either systematically or haphazardly. Those participants using a comprehensive approach to triage worked logically from head to toe or through the application of the sepsis guidelines (The UK Sepsis Trust, 2016). A systematic approach provided clarity and ensured thoroughness; the informal approach did neither. More often than not, the participants expressed feelings of anxiety and apprehension owing to the lack of visual cues, an absence of telephone triage training and the lack of a supportive pathway. These findings are similar to those of previous studies (Eriksson et al, 2019; Wilson and Williams, 2000).

The findings echo earlier work in that they demonstrate that, if an HV were unsure of the problem or if they considered that a medical assessment were necessary, they would use GP services, thereby ensuring the patient’s safety (Edwards, 1994). The vulnerability attached to the role is evidenced through the surprising finding that one participant adopted risk-minimising actions by making unnecessary GP referrals. This waste of scarce financial resources was considered justifiable by the participant to manage their poor self-confidence when unable to determine the problem, thus maintaining their professional accountability. Previous studies had not made a finding of this type.


Implications and recommendations

The findings revealed that a lack of confidence among most participants can lead to the missing of signs or an overcautious onward referral. The lack of telephone triage training for HVs leads to inconsistent assessment methods and heightens the risk that vital information will not be exchanged. 

To support a systematic assessment that ensures the safety of service users, the implementation of a framework is recommended. A clinical decision software program is advocated. This would guide HVs through specific algorithms to help them assess the urgency of each problem; support their knowledge, expertise and critical thinking; and offer recommendations on the course of action. Such programs support care that is safe, consistent and of a high standard through a systematic assessment process (Kawamoto et al, 2005; Kirkley, 2019; Monaghan et al, 2003). 

HVs are generally not sick children’s nurses. Therefore, to prevent inconsistent assessment processes from being applied and reduce the risk of errors, the triaging of children who are clinically unwell by HVs should cease. In such cases, it is recommended that parents are directed to the NHS 111 service. 

A single-point-of-access (SPOA) service is recommended. Calls to it should be recorded, as this offers enhanced clinical outcomes and also allows for the performance of staff to be monitored for quality-assurance and training purposes (Hosking and Gibson, 2016; Raine et al, 2005). Where calls are recorded, nurses are able to develop their knowledge and skills following review, supervision and reflection, thereby improving patient care (Wahlberg and Björkman, 2018).

It is vital that those staffing the SPOA service are trained in telephone triage. They need to have excellent communication skills and be technically proficient to offer the most appropriate healthcare advice to service users and eliminate risk-averse practices (Murdoch et al, 2015). 


Limitations

The original plan had been to interview 20 participants. Unfortunately, owing to the Covid-19 pandemic and the guidance on social distancing (Public Health England, 2020) only 14 participants were able to contribute. Further interviews were not possible for a variety of reasons, including staff sickness. Although the number of participants fell short of the anticipated sample size, it was comparable to those of preceding studies, while the data obtained was sufficient to address the research question. Nonetheless, the findings are drawn from a small sample of self-selected participants employed in a single NHS trust in England. Other participants and trusts may have had different experiences. A nationwide survey of HVs would add insight into the scale and complexity of the issues identified here.  


Conclusion

HVs feel that they cannot effectively assess over the telephone because they cannot observe the child. Their assessment is further compromised by the lack of sufficient guidelines and triage training. These factors influenced the HVs’ ability to handle duty calls effectively. This commonly left them feeling vulnerable and anxious. In some circumstances, it led to the adoption of risk-minimising actions that created resourcing ramifications for other primary healthcare services. 

It is recognised that further infrastructure is necessary to reduce variations in practice. Practitioners need to be supported with appropriate training, thereby ensuring that a high standard of service is delivered throughout the telephone triage process.

Debbie Outram is a senior health visiting practitioner at Kent Community Health NHS Foundation Trust. Dr Lesley Dibley is a reader in nursing research and education at the University of Greenwich.

Image credit | iStock


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