Annotated Bibliograpgy

Clinical communication skills

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B oth telephone consultation and telephone triage come under the umbrella of eHealth. The Royal College

of Nursing (RCN) (2013) defines eHealth as an aspect of health care that is concerned with:

promoting, empowering and facilitating health and wellbeing with individuals, families and communities, and the enhancement of professional practice through the use of information management and information and communication technology.

Telephone consultation is not a new process (Nauright et al, 1999). Advising and guiding patients by telephone has been identified in literature since the 1960s and has been com- monly used by GPs, particularly in managing out-of-hours calls, for many years now. Along with telephone triage, which is defined as the process of sorting and prioritizing patients for care (Manchester Triage Group, 2006), telephone consultation became much more widely used by nurses following the introduction of NHS Direct in 1998.

A study by Edwards (1998) highlighted that there was an ethical and emotional cost to decision-making in telephone consulta- tions. The study demonstrated how nurses responded to being called to account for decisions made, and reviewed strategies in place to reduce risks which may have conflicted with clinical judgement. Edwards found that there was a fear of the conse- quences of risk-taking in situations where nurses had little control and, in such situations, clinical judgement ‘was greatly influenced by the nurse’s own degree of self-belief’.

Practice nurses are now adopting roles that were previously within the remit of GPs. The evidence suggests that the level of care pro- vided by practice nurses is comparable to that of GPs, and patients are satisfied with the service delivered in the management of minor illness and long-term conditions (Bonsall and Cheater, 2008). However, Edwards (1998) suggests that nurses in these developing roles acknowledge professional vulnerability and anxiety with regards to role uncertainty, ambiguity and limited support from colleagues.

Using telemedicine in clinical decision-making

Veronica Andrews is lecturer in adult

nursing and continuing professional

development, University of York

Submitted 23 May 2013; accepted for

publication following peer review

11 November 2013

Key words: Telephone consultation,

diagnosis, communication, consultation

models, clinical skills, advanced practice

Veronica Andrews

considers the core

skills required to

diagnose patients

over the telephone,

and the educational

support that is

available to prepare

practice nurses for

this role

In the UK, political agenda is driving changes in health care and promoting new ways of working. Lord Darzi’s (2008) report suggested that GPs should become more accessible and responsive in delivering high quality standards. Likewise, over the past decade, the role of practice nurses has evolved to accommodate patients with long-term conditions, minor illness and, of particular relevance here, telephone consultations. Bunn et al (2004) suggest that this has partially come about as a response to increased work- loads for GPs and the need to manage the demand for same-day appointments.

Thus, the issue that needs to be addressed is how practice nurses are being prepared for this new role. Wilson and Hubert (2002) recognize that the skills and knowledge required to undertake this role are ‘complex and multifaceted’, which indicates that prep- aration is essential to minimize any possible risks in this form of consultation. However, there is currently very little available in the form of education or training to enable pro- fessional development in this field of practice.

What is a consultation? The consultation is most often defined as a voluntary and time-limited process in which a person seeks assistance from a consultant regarding a problem, and seeks options for resolution (Wynne et al, 1986; Conoley et al 1991). Kaufman (2008) perceives the consultation as:

a private and intimate interaction between clinician and patient. It assists in the diag- nosis of health problems in clinical settings and has traditionally been the domain of medical practitioners.

In general, the consultation between clinician and patient is related to aiding the diagnosis, resolving the problem and making change through discussion. A further definition by Dickinson (2000) states:

Talking to people is the most power- ful aspect of our work. In a purposeful conversation, we have a forum for effecting change.

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Over the years, nursing roles in primary care have expanded considerably to include caring for people with minor illness and injury, managing long-term medical condi- tions, independent prescribing, staffing walk-in centres and delivering out-of-hours care. As the scope of care provided by the practice nurse workforce increases, it is important for the practice nurse as an individual to develop skills and knowledge in the management of long-term conditions and minor illness and prescribing (Kaufman, 2008). In order to do this effectively, history taking and consulta- tion skills must be regarded with equal importance. In the telephone consultation, all these skills are brought into play.

Structured consultations When considering the definition of the consultation, it is worth reflecting on how a structured consultation can enhance the patient experience and give direction to the process. Many consultation models have been developed over the years. One of the most popular consultation models, which can be utilized in most clinical settings, is the Calgary-Cambridge model (Silverman et al, 2005). The model promotes a collaborative and holistic approach, thus moving away from the traditional paternalistic approach. As this is a patient-centred model, the patient is an equal partner in the consultation. The key principle is that of communication skills, which provides the foundation for the attitudes and concerns met in practice.

Consultation skills Good consultation skills have always been relevant to nurses. Themes which practitioners recognize as constituting a good consultation are listed in Table 1.

Although consultation skills may be taught in an academic setting and practised with simulated patients, attempting to apply these skills in the short time spent with a patient can be quite daunting. With support from a medical mentor, practice nurses who have completed an independent and supplementary prescribing course must achieve competence in the consultation process in order to meet the standards set by the NMC (2006). However, supported practice may not be available for all nurses currently in practice.

Good consultation skills cannot be acquired by merely sitting through one consultation, but will only develop through frequent expo- sure and supported practice. Moulton (2007)

proposes that consultations are a learning experience and discusses the four stages that a practitioner will go through when developing their consultation skills (Table 2). Moulton suggests that this transitional process will be quickly absorbed into conscious competence. The practitioner needs to be confident in the consultation process before embarking on telephone consultations.

Communicating effectively Underpinning the consultation is the ability to communicate well. Research shows that health professionals with good communica- tion skills recognize patients’ problems more accurately and that patients report higher levels of satisfaction with their care (Bowles et al, 2001). Hulsman et al (1999) describes communication as:

the fundamental instrument by which physician and patient relate to each other and attempt to achieve therapeutic goals.

If a patient feels respected and valued by the clinician, they are more likely to reciprocate and better clinical outcomes may be achieved.

In a health-care setting, communication is a two-way exchange between the patient and provider. This can take place face-to-face, over the telephone or using the written word, such as letters or emails (Fleisher et al, 2008).

There has been substantial research into doctor-patient commu- nication over the last 30 years (Sheldon et al, 2006). Medical schools now include some form of communication education in their curriculum, following the report by the British Medical Association (2004), Communication Skills Education for Doctors . One of the key recommendations in the report states that medical schools must be encour- aged to provide the best possible communication skills training as part of

Table 1.Themes of a good consultation The patient presents with a single, uncomplicated problem which the practitioner can recognize and manage accordingly

The patient presents with a challenging group of symptoms which the practitioner makes sense of and can advise or manage accordingly

The practitioner adds value to the consultation by advising the patient on smoking cessation, for example

Test results confirm a diagnosis which is uncomplicated to treat, allowing the practitioner to reassure the patient that the condition is not life-threatening

Each patient seen in the practitioner’s shift has been advised or managed accordingly

From: Moulton, 2007

Table 2. Stages a practitioner goes through when developing consultation skills Unconscious incompetence

The practitioner is unaware of what he/she does not know and may be oblivious to risks

Conscious incompetence

Learning and understanding are developing and the practitioner is becoming aware of how much he/she does not know

Conscious competence

Knowledge and competence are becoming embedded. The practitioner knows how much he/she knows and practises accordingly

Unconscious competence

The practitioner does not consciously think of what he/she knows as knowledge, and skills are fully embedded

From: Moulton, 2007

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the core undergraduate curriculum. Bowles et al (2001) argue that the commu-

nication skills of nurses have come under criticism for many years as the theoretical educational approaches to communication skills in nursing education are weak. This has been largely addressed by the response of the Nursing and Midwifery Council (NMC) to the changing needs, priorities and developments in health and health-care delivery in the new Pre-registration Nursing Programme (NMC, 2010a). The Standards for Pre-registration Nursing Education states (NMC, 2010b):

All nurses must use excellent commu- nication and interpersonal skills. Their communications must always be safe, effective, compassionate and respectful. They must communicate effectively using a wide range of strategies and interventions, including the effective use of communication technologies.

This statement can be applied to practice nurses who are working with patients in the local community and at the practice, where nurses are developing their roles and taking the lead in managing patients with long-term conditions, as well as those accessing first- contact health care with minor illnesses.

Telephone consultation skills Consulting by telephone has become routine in primary care and has evolved in order for practice teams and out-of-hours providers to adapt to increasing patient demand (Males, 2012). Thus, it is imperative to ensure that telephone consultations are clinically safe and effective. In order for nurses in practice to achieve this, it is essential to have the appropriate education and preparation to ensure this process is safe and effective.

Males (2007) suggests that although health professionals may receive training in commu- nication and consultation skills, whether this prepares them for the telephone medium remains questionable. As Silverman et al (2005) have discussed, the use of verbal and paralinguistic communication is particularly significant when considering telephone con- sultations. In this type of consultation, the absence of visual cues may complicate the consultation. It can also be more difficult to establish rapport with the patient. As the practice nurse is unable to draw on visual signs, acute verbal and listening skills are essential. It is important to ensure that the practice nurse is communicating directly with

the patient and that the environment the patient is in will protect confidentiality.

When carrying out consultations with patients over the telephone, it is often more difficult to establish rapport and develop relationships which may help with subse- quent diagnostic reasoning. Offering to call the patient on a different number or giving the patient the opportunity to move to a more private place may help in developing rapport. The practice nurse should also try to pick up on audible cues such as breathlessness or wheeze. The tone and pitch of the patient’s voice can also serve as a useful indication of anxiety or pain, and this may lead to a differ- ent line of questioning when there are no visual cues (Carey, 2005).

Edwards (1998) suggests that the practice nurse should create an image of the caller during the telephone call and use this image to support decision-making. Communicating effectively is vital to this process and the practice nurse must always be able to justify his/her decisions and actions, and use this information to continue developing skills and knowledge (Breslin and Dennison, 2002).

Political influences in health care In 2007, the Department of Health (DH) introduced the concept of NHS Direct, a 24-hour health advice telephone line staffed by nurses. The service was introduced nation- wide in 2000, with a single number for England. In 2012, the service received approximately 4  million telephone calls and separate services were introduced in Scotland and Wales (NHS Direct, 2013).

In England, NHS Direct also introduced NHS 111 in April 2013. The aim of the service is to improve patient access to care services when help or medical advice is needed but the patient does not need emergency services. However, as NHS Direct will be closing down in March 2014, NHS 111 services will be delivered locally where available.

Additionally, the publication of Our Health, Our Care, Our Say: A New Direction for Community Services (DH, 2006) and Liberating the NHS: Developing the Healthcare Workforce (DH, 2012) have led to changes in health-care delivery. Particularly in primary care, new roles are being devel- oped, with increasing numbers of specialist practitioners. In some primary care settings, for example, advanced nurse practitioners provide services for patients with depression, rheumatoid arthritis and heart failure

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amongst other conditions (RCN, 2012). The nursing workforce is also under the

microscope. Role design, skills and compe- tencies, and education and training are being introduced to meet service needs as more care is being delivered in the community and closer to home (DH, 2008). Telephone consultations are an integral part of the care being delivered locally. Nurses in the com- munity telephone patients to monitor pain levels and progress, including people who have been discharged from secondary care after surgery or have long-term conditions.

Patients requesting same-day appointments are referred to practice nurses and decisions are made regarding treatment or appoint- ments. These are cost-effective practices and are likely to be developed further as the cost of health care remains under scrutiny. Although the workforce is shrinking, the expectation of high quality care remains at the fore (Bonsall and Cheater, 2008).

Equity and Excellence: Liberating the NHS (DH, 2010), which was passed by Parliament to become the Health and Social Care Act 2012, is continuing this process. The Act led to the creation of clinical commissioning groups, which made GPs and other clinicians accountable for securing high quality services and allocating the use of resources. The Act also details improving the quality and choice of care for patients as a key concept. As this will always be problematic when considering budgetary restraints and the needs of patients in primary care, it is essential to continue developing cost-beneficial services in order to manage these expectations.

Health Education England also ensures that the education and training investments that employers make in their workforce are transparent. Local Education and Training Boards (LETBs) support innovation and devel- opment and consider the appropriate educa- tion for practice nurses who are taking on the challenges of telephone consultations. Additionally, LETBs invest in the education, training and continuing professional develop- ment of the wider health team.

Advanced nursing roles The acquisition of clinical skills and knowledge is an aspect of practice that cannot be ignored as many practice nurses who carry out telephone consultations are working without algorithms. In such situations, practice nurses have to begin making differential diagnoses with very limited information. This is quite

different to nurses working in NHS Direct who have access to algorithms.

The Clinical Assessment System by NHS Direct, for example, was developed to standardize interactions between nurses and callers (UK Medicines Information, 2007). Although these systems minimize risk and guarantee consistency, algorithms may reduce professional expertise (Greatbatch et al, 2005).

There should be some consideration as to how the practice nurse role is evaulated and audited to ensure that the needs of patients are met and that the practice is safe, effective and minimizes risk. Another area to consider is whether the role involves the clinical skills and knowledge of an advanced nursing role. The NMC (2005) defines advanced nurse practitioners as highly experienced members of the care team who are able to diagnose and treat patients’ health-care needs, and make referrals to appropriate specialists.

When considering the expectations of a nurse in a telephone consultation role, the NMC has set out the following criteria:

➤ Take a comprehensive patient history ➤ Use expert knowledge and clinical judgment to identify potential diagnosis ➤ Refer patients to an appropriate specialist ➤ Use extensive practice experience to plan and provide skilled and competent care to meet patient’s health and social care needs, involving other members of the health-care team as appropriate ➤ Ensure the provision of continuity of care, including follow-up visits ➤ Assess and evaluate the effectiveness of the treatment and care provided with patients, and make changes as needed ➤ Work independently ➤ Make sure that each patient’s treatment and care is based on best practice.

The key skills involved in this process are listening and questioning skills, which serve as substitutes for visual cues in face-to-face consultations.

Conclusions Telephone consultation is an ever-evolving practice. Although nurses working in general practice are at the forefront of these changes, educational support for nurses moving into this area of practice is very limited. The ability to provide high quality care for patients is an aspiration that can only be attained if all staff involved in NHS services are equipped with

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high quality education and training. As new roles are emerging and new

technology changes the way the NHS works, assumptions should not be made about nursing skills and knowledge. Instead, appropriate education and development should be made accessible to practice nurses in this field of care. Telephone consultation skills should be an essential part of continuing professional development for practice nurses.

Furthermore, employers and higher education institutions need to communicate with nurses in the changing world of health care and workforce planning. Education and training needs should be tailored with the aim of enabling staff to respond more effectively to this dynamic environment.

Conflict of interest: none declared.

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Key Points

➤ Consulting by telephone has become routine in primary care

➤ Educational support for practice nurses moving into this area of practice is very limited

➤ Telephone consultation skills should be an essential part of continuing professional development for practice nurses

➤ Practices should implement a process of evaluating telephone calls and auditing outcomes to improve quality of care

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