Principle 1: Therapeutic nurse-client relationships

The HNC is accountable for establishing and maintaining the therapeutic nurse-client relationship when using the telephone in the provision of care. By using professional nursing knowledge and skill with a caring attitude and behaviour, a relationship built on trust and respect is more likely to occur. Visual prompts, gestures and physical contact are missing making communication by telephone more challenging. Communicating effectively is central and can be enhanced through asking open-ended questions in a logical sequence, with attention and sensitivity to the patient’s level of understanding. Asking leading questions and use of medical jargon are to be avoided. Listening for verbal, emotional and behavioural cues that may convey important information is essential. Where possible, always speak directly to the patient. It is important to avoid premature conclusions regarding a patient’s situation or problem and to avoid premature closure of the call.

Principle 2: Providing and documenting care

Provision of care begins when the HNC answers the telephone. The HTC needs to provide a physical environment that will support the HNC in maintaining confidentiality during the call and while updating the patient health record. Starting with a documentation form, rather than a protocol, guideline or algorithm is important to ensure a systematic approach to the collection of data. Once a general sense of the problem emerges, the use of a guideline that best matches the patient’s presenting problem will serve to ensure the safest course of action. The Canadian Association of Nurses in Hemophilia Care (CANHC) created telephone guidelines for specific problems in common inherited bleeding disorders to be used as decision support tools when providing care over the telephone. The distinction between decision support and decision making tools honours nurses’ professional judgement. A disposition-based template modeled after Julie Briggs telephone triage protocols for nurses was used [3,4]. Each of the 16 guidelines includes key questions, identifies symptoms that require emergent, urgent, acute or non-acute medical attention, as well as home care instructions. Eleven of the guidelines are repoduced here:

Use of the CANHC Telephone Guidelines as a decision support tool serves to collect data systematically and enhances pattern recognition. Their use decreases the likelihood of overlooking important facts. They function as a checklist to prevent oversights, decrease ambiguity, supplement knowledge deficits and help a busy HNC focus. The guidelines are evidenced-based and have been reviewed by members of the Association of Hemophilia Clinic Directors of Canada (AHCDC). Every effort was made to ensure that the guidelines were valid, reliable, clinically applicable, flexible and clear, although to date, this has not been studied.

Once a detailed and structured history has been obtained through use of a documentation form and problem specific guideline, the implementation phase of telephone triage is the advice given regarding patient disposition. The HNC provides follow-up instructions, with a disclaimer to the caller. To ensure that the caller understands the plan of care, it is helpful to request that the caller repeat the advice given. Ask if the caller has any outstanding questions. Permit the caller to disconnect first.

Nurses are required to document care provided to patients through telephone contact in accordance with their licensing body and employer. Documentation provides a record of the quality of care provided. It enhances communication among the interdisciplinary care team. Lack of documentation leaves a HNC vulnerable to a malpractice claim. It is presumed that if it is not documented, it was not done. The documentation form should indicate the need to capture the date and time of the call, the name and number of the caller, patient identification and reason for the call. Free text space for recording a detailed and structured history, a clear description of the recommended disposition and advice regarding home care instructions is required. Identification of the telephone guideline used will provide supportive documentation for the disposition decision arrived at by the HNC

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Principle 3: Roles and responsibilities

The HNC is responsible for recognising whether he or she has the knowledge, skill and judgement to meet the needs of the patient. Provision of care over the telephone requires advanced communication skills and competencies that overcome the barriers to data collection in the absence of face-to-face contact. Until such time that the HNC has acquired sufficient foundational disease-specific knowledge and has become familiar with his or her patient population, provision of care over the telephone may take the form of message taking, rather than advice giving. The HTC environment needs to be supportive to reduce risks associated with telephone triage. A more experienced HNC or the medical consultant needs to be both available and approachable for the novice HNC to consult with to aid in sound decision-making regarding patient disposition. A supportive practice environment is also enhanced through clear and identified practice support tools, such as the CANHC Telephone Guidelines.

Principle 4: Consent, privacy and confidentiality

Provision of care over the telephone is subject to the same college standards and government legislation. Consent is implied with most telephone triage situations. When a patient calls it is important that HNCs identify themselves and the nature of the help they can provide. All personal health information must be kept confidential. Ensure that both the caller and the HNC are in a secure environment where privacy will be ensured. It is imperative that the HNC understands what constitutes a breach of confidentiality such as:

Documentation provides a record of the quality of care provided. It enhances communication among the interdisciplinary care team. Lack of documentation leaves a HNC vulnerable to a malpractice claim

Principle 5: Ethical and legal considerations

Each HNC is accountable for his or her own actions. Answering the telephone establishes a duty of care and it is a nurse’s duty to do no harm. Use of the telephone in caring for patients increases risk to the nurse. Risks are reduced by establishing and maintaining a therapeutic nurse-patient relationship and by ensuring that patient information is secure.

Principle 6: Competencies

Nurses providing telephone triage require nursing knowledge, judgement and skill beyond that expected from an entry-level nurse. In depth clinical knowledge and strong skills in assessment, communication, critical thinking and evidence-informed decision-making are critical for nurses providing advice to patients without the benefit of face-to-face contact [5]. The HNC needs to possess current and in-depth knowledge related to the care and treatment of patients affected by an inherited bleeding disorder. The HNC is expected to practice within scope and to develop skills through continuing education and mentorship program.

Conclusion

Use of telecommunication technologies by nurses in the delivery of care for patients with specialised health care needs continues to evolve. Use of standardised, evidence-based telephone guidelines is one tool that the HNC can use to minimise risk when providing care to patients over the telephone. Decision support tools, however, do not replace professional judgement. HNCs must know and function within their scope of practice and maintain accountability for their clinical decisions and patient outcomes.