Maternal child health triage research project literature review

Australian Healthcare & Hospitals Association (AHHA)

JustHealth Consultants (JHC)

Maternal Child Health Triage Research Project

FINAL Literature Review

For Healthdirect Australia

5 November 2013

Maternal Child Health Triage Research Project FINAL Literature review 5 November, 2013

AHHA-JustHealth Consultants Page 2

1. Executive Summary ...................................................................... 3

2. Introduction ................................................................................. 4

2.1 Purpose ....................................................................................................................... 4

2.2 Context ....................................................................................................................... 4

2.3 Scope .......................................................................................................................... 4

2.4 Search strategy overview ........................................................................................... 5

2.5 Organisation ............................................................................................................... 5

3. Defining the issue .......................................................................... 6

4. Objectives ..................................................................................... 8

5. Literature search method .............................................................. 8

6. Results ........................................................................................ 10

6.1 Global overview of key themes ................................................................................ 10

6.1.1 The international dimension ...................................................................................................... 10

6.1.2 Professional autonomy and IT-based systems ........................................................................... 11

6.1.3 Who uses telephone triage/support services and why .............................................................. 13

6.1.4 Your call is important to us - scripts and sincerity ..................................................................... 14

6.1.5 Nurse and user perspectives ...................................................................................................... 14

6.1.6 Risk management ....................................................................................................................... 15

6.2 Guideline evaluation frameworks from the literature ............................................. 16

7. Conclusions ................................................................................. 18

References ...................................................................................... 20



1. Executive Summary

This broad purpose of this literature review was to identify the existence and availability of maternal and

child health telephone triage guidelines both in Australia and internationally and describe the key issues

around these.

The method for the review was based on a search of the academic databases and grey literature conducted

during July and August 2013 to retrieve articles related to telephone triage services. Because of the breadth

of the topic, the search terms were broad and the search strategy drew upon the grey literature as well as

the academic literature.

The key findings of the literature review indicate that telephone triage services offer a clinically effective

and cost effective way to assess the needs of parents and children, and provide information and advice.

The most common scenario in telephone triage occurs with registered nurses working in a call centre with

computerised protocols or algorithms to guide the clinical advice provided to callers. However, the

existence and availability of maternal and child health telephone triage guidelines, protocols or algorithms

is difficult to assess. Whilst the literature frequently refers to the existence of such guidelines, and a

number of white papers, research by special interest groups, statements by professional bodies,

government departmental publications, practice guidelines and organisational protocols make reference to

maternal and child health telephone triage guidelines, the guidelines themselves are not fully accessible in

the literature. Perhaps because of the prevalence of in-house guidelines, the market for teletriage

guideline products appears to be limited, and the literature suggests that it is largely dominated by a single

product.

The review concludes that whilst there has been a considerable amount of research conducted into various

aspects of telephone triage services, such as effectiveness and safety, this research is not definitive. Many

studies focus on one service in a particular institutional setting, thus limiting the degree to which its results

can be generalised across all services. A comprehensive comparative review of the guidelines and protocols

that inform maternal and child health telephone triage services was not identified in the literature and

demonstrates the opportunity for future research in this area.



2. Introduction

2.1 Purpose

This literature review provides the intellectual and academic context for a report on maternal and child

health telephone triage services prepared by JustHealth and the Australian Healthcare & Hospitals

Association for Healthdirect Australia in August and September 2013.

The purpose of the literature review was twofold: to provide a global view or big picture understanding of

the key areas and issues that have been studied and described within the larger world of telephone support

and teletriage, and to focus on more specific issues related to distinctive child and parent/family telephone

services and delineate the key research findings within these specialised services.

2.2 Context

The context for this literature review is underpinned by the requirement to deliver to Healthdirect a clear

understanding of the existence of, the quality of and the availability for licence or purchase, of maternal

and child health telephone triage guidelines both in Australian and internationally. This review approached

the literature from the perspective that call centres and helplines do not operate or exist in a societal

vacuum. Numerous studies and commentaries have contributed the valuable insights from medical,

nursing, sociology, occupational psychology, management and organisational theory perspectives. These

works are crucial in helping understand the bigger picture within which telephone services operate, and the

literature search was conducted with this in mind.

2.3 Scope

The focus of the review was identifying which, if any, guidelines for maternal and child health and

paediatric nurse triage are described in the literature, both in Australia and globally. The scope of the

review was limited to the identification of the major themes and salient current concerns around telephone

triage guidelines and program operations in the maternal and child health sector.

While there are specific web-based online support and information services available such as those that are

proposed as responses to callers who may be predominantly seeking general health information, this

review is limited to telephone-based services.1

Although paper-based guidelines are referred to in this paper, the evaluation of these guidelines is outside

the scope of this review.



Additionally, it appears that many guidelines in use have been adapted for their intended purpose from

legacy systems. Such systems may not have an obvious lineage back to the research literature and have not

been considered in this review.

2.4 Search strategy overview

This literature review is based upon wide and in-depth consultation across electronic database collections

in health, medicine, nursing, social sciences, computer science, organisational, management and thesis

collections. Genealogical checking of existing references and papers yielded additional sources. Open

Google searching and detective work using reference manager software, Bookends, and a range of social

media such as Twitter, uncovered other information. As telephone support services have regularly featured

as news stories and media reports, especially in the United Kingdom and especially around the political and

media sensitivities surrounding telephone triage, results from these sources are incorporated where

appropriate.

2.5 Organisation

As anticipated in such a wide and burgeoning area of research, the literature is considerable, but not all of

it is relevant to the area of maternal and child health. This literature review is organised around the key

themes and issues evident in telephone triage protocols and guidelines in the maternal and child health

sector, and the implications these may have for service provision.

There is a focus on the provision of definitions, clarification of terms and in exploration of the different

types of telephone triage services that exist.

This myriad of definitions together with a

high volume of heterogeneous studies

makes reviewing and making sense of the

evidence on the topic a challenge. This is

further complicated by the debate

surrounding the quality of research in this

field and the shortcomings of various

methodologies for assessing telemedicine.

(Brettle et al.,2013)



3. Defining the issue

The literature on the topic of telephone triage is complex. It has challenged even major research groups

undertaking full scale systematic reviews.2 It is regularly noted in the literature that terms and terminology

within telehealth are often confusing and problematic. Grasping such distinctions is crucial for

understanding the literature and for the planning and provision of children’s tele-services.

There are two distinctly different purposes to be achieved via telehealth services for parents of children

aged birth to six years. The first is primarily a medical tele-triage and advice service directed at parents of

children who are unwell or injured. Parents calling this type of service may need urgent or non-urgent

advice or care. Nurses working in such a service usually follow medically designed telephone triage

protocols adapted originally from hospital emergency room triage protocols. The desired outcomes of this

type of service could be proposed as prompt, accurate assessment and safe management and referral of

paediatric medical and trauma emergencies.

The second type of service is well-child tele-health information, care and advice service directed at parents

who require information and support around parenting issues such as infant feeding and sleep, infant and

child nutrition, and growth and development. Nurses working in such a service are usually specialist child

and family health nurses who approach telehealth as a replacement consultation, using specialist

approaches to care such as the family partnership model 3 and organisation clinical practice standards to

guide their decision making trail. The goal of a well-child or parent help line might be, for example,

consultation on a wide range of issues concerning infants and children from birth to five years of age4 or to

provide telephone support for parents of children from birth to 12 years about health, behaviour and

relationships for parents and people working with children and young people.5

The definition of what constitutes a guideline or protocol is important to make, as it differs between the

services. It appears that in medical tele-triage and advice, a guide or protocol refers to a decision support

system that uses a flow chart or algorithm to determine nurse direction in the consultation and nurse

responses.

There appears to be no consistency in the meaning of each term, hindering the progression and

understanding of this mode of practice. There is no universally agreed definition or terminology

that will clarify this area for either researchers or service providers. The terminology used to

describe this practice varies considerably.

(Nursing and Midwifery Telehealth Consortia, 2013)



Examples of this include the United Kingdom based Capita Clinical Solutions telephone clinical assessment

service used as a medical adjunct by PlunketLine in New Zealand and the Centaurus Call Center Software:

Nurse Triage system with content by Schmitt/Thompson, used across the United States.

In well-child tele-health information, care and advice service there are several guides that are used to

ensure quality care. The first is a guide to telehealth protocols. This may include information on how to use

a particular system of telehealth and organisational protocols on health related call priorities such as

prioritising information and support for babies under three months and breast feeding issues, such as those

used by Ngala in Western Australia. The second includes the clinical practice guidelines that frame the

nursing work of those employed to work within the specialisation of maternal child and family health

nursing. The responsibility of keeping these current, lies with the employing organisation. The third guide is

the web based information service that nurses refer to when discussing care, providing advice and

educating parents. These are kept current by their authorising body. For example, the Raising Children’s

Network6 is supported by the Australian Government Department of Families, Housing, Community

Services and Indigenous Affairs with member organisations including the Murdoch Children’s Research

Institute, the Parenting Research Centre (formerly the Victorian Parenting Centre), and the Royal Children’s

Hospital Melbourne. The South Australian Parenting and Child Health7 is owned by the Government of

South Australia and auspiced by the Women and Children’s Health Network.

Therefore, this broad field of tele-health encompasses many services that often have a distinct and

different focus but may be variously described as counselling helplines8, telephone triage9, out of hours

telephone advice service10, telenursing support line11, teletriage12, Parentline13, telephone hotline14, health

information line15, telephone care line16, paediatric telephone triage17, or telephone consultation service.18

http://www.lvmsystems.com/download/demos/Sales%20Demo%20-%20DotNet%20Nurse%20Triage.htm

http://www.lvmsystems.com/download/demos/Sales%20Demo%20-%20DotNet%20Nurse%20Triage.htm



4. Objectives

The objectives of the literature review are focused on:

Defining the breadth of maternal and child health telephone triage guidelines, protocols or

algorithms available in Australia and internationally;

Researching the existence and availability of maternal and child health telephone triage guidelines

in Australia and globally, as described in the academic and grey literature;

Summarising the key issues that may have an impact on the development and delivery of maternal

and child health telephone triage guidelines or protocols.

5. Literature search method

For this literature review we consulted widely and in depth across numerous electronic database

collections in health, medicine, nursing, social sciences, computer science, organisational management and

thesis collections.

The key databases used were: PubMed, Medline, Proquest, Social Services Abstracts, Sociological Abstracts,

CINAHL, Cochrane, ERIC, Google Scholar and the King’s Fund tele-health

database http://kingsfundlibrary.co.uk/telehealth/

Publishers' online sites and databases were also used. Key sources were SAGEPUB, Science Direct, Wiley,

Elsevier, Internode and Mary Ann Liebert, Inc.

Specific telemedicine journals including the Official Journals of The American Telemedicine Association:

Telemedicine and e-Health and the Journal of Telemedicine and Telecare were consulted.

The majority of literature was retrieved via PubMed, Medline, CINAHL, Google Scholar and the various

journal publishers' sites.

The search strategy also followed up numerous websites and web links from the research and grey

literature into various professional associations related to telemedicine/telehealth; related government

departments; other publications; and mass media commentary on various teletriage services.



The list of 160+ websites and web links to stories, reports, files and articles consulted is available via

Evernote library when viewed as a guest:

https://www.evernote.com/pub/pprofpopp/ahhahelplines#b=971acb66-d10d-4364-9ed5-

3d6257edd196&st=p&n=4b1a61c2-8b18-4993-9e76-69b761308245

Literature from 2000 onwards was generally included. Earlier work from the 1990’s which is still widely

cited and therefore seminal or still influential, was also included. The focus was on the latest works as this

is a fast-developing field of study. 180 of the 465 references in the review database are from the last 5

years (2009-20130).

The review was confined to publications in English.

The key search terms used were: telehealth/tele-health; telemedicine; telephone triage; teletriage/tele-

triage; telnursing; maternal-child telephone support; parent support line; helpline; telephone helpline; e-

health; algorithm; guideline; practice guidelines; clinical guidelines; out of hours care (OOHC); parenting;

call centre; telephone assessment; tele-health care; tele-health consultation; evaluating guidelines;

guideline appraisal; telepediatrics; pediatric triage; pediatric call centre; maternal child health line;

telepractice; computerised decision support (CDS and CDSS); telephone counselling.

Terms relating to specific tele-triage services were also searched. These included NHS Direct; NHS 24;

Healthline; Parentline; Plunketline.

Papers were selected for inclusion or citation based on their relevance to the objectives of the

project. Those cited and used in the review are those that most closely relate to the focus key words of this

report, including tele-triage, children, parents, parent helplines, paediatric triage and maternal-child

telephone support; works related to guidelines and standards and evaluating or appraising clinical

guidelines; and the algorithms used in telephone support services and the staff.

Particular weighting was given to the rigorous studies such as major service reviews and evaluations,

systematic reviews in tele-health and to studies deemed widely cited and influential. More anecdotal and

commentary pieces were included if they are challenging and pointed in their commentary, perhaps

expressing widely held views among professional groups, the general public or the parent/child community

that this proposed service seeks to serve.

The number of Australian studies which addressed the objectives of the review was limited, so the

international research is relied on quite heavily.



6. Results

6.1 Global overview of key themes

This big picture overview provides the key points in relation to the current state of research and

scholarship. These points are organised around key themes or issues that have the greatest prominence

within the literature. The key themes that generate the most discussion and that appear to be most salient

within this current project are described below.

6.1.1 The international dimension

Telehealth in general is now truly international.19 The range of studies and reports consulted for this

review come from over a dozen countries including New Zealand20, Japan21, Lebanon22, Norway23,

Sweden24, Netherlands25 and the USA.26

The review suggests that some countries are more advanced in their telehealth systems and services

development than others. For example, both Canada and the United Kingdom have invested in evaluation

and research regarding their various telehealth initiatives and as a result, many key studies and reports are

from the United Kingdom or Canada. The United Kingdom’s NHS Direct service, for example, has been

extensively researched and evaluated from various clinical, economic, sociological, political and other

perspectives.27 Canada has also been at the forefront of telehealth research through their numerous

provincial and national programes.28

Key points

Telehealth is global and international in its technology and in our growing research

understandings.

There is a growing consensus internationally on key principles and evaluative

criteria for telehealth.



6.1.2 Professional autonomy and IT-based systems

The literature suggests that the relationship and interaction between the experience and professional

knowledge of the nurse answering a call and the existing guidelines or protocols that are used by the

particular telephone helpline are critical. At first glance, these may seem an esoteric concern, but this

tension, or what Russell (2012) calls “the paradox of the algorithm”29 goes to the heart of the operation and

ultimately the success of any telephone support or telephone triage service. This issue of the role of

professional judgement and individual decision-making within a computer-programe based decision system

that prioritises standardisation and algorithmic thinking, is crucial to both the design and operation of any

maternal-child telephone support service.

The tightly structured and detailed decision support algorithms and clinically focused guidelines and

protocols are more widely used in paediatric triage services30, whereas maternal-child telephone support

lines opt for more of a counselling approach.31 This is clearly not an either/or dichotomy as triage nurses

will certainly use listening and empathetic skills with callers just as maternal-child telephone support nurses

will often work with guidelines.

There is general agreement within the literature that paediatric triage and maternal-child telephone

support services involve a different focus and different modes of thinking and engagement on the part of

the staff responding to the calls. Paediatric triage services are characterised more by algorithmic thinking

and processes supported by detailed clinical guidelines and protocols for a wide range of child health and

illness, for example guidelines for how to respond to the child who is vomiting; who has had a head injury;

or who is feverish. Within this mode of thinking and practice, adherence to the steps within the specified

guidelines is valued and often mandated. Within this model, nurses or call takers veering off script is taken

as a source of error.

Blank et al’s systematic review of protocol compliance found that: “Triage decisions rated as appropriate,

varied between 44-98% and compliance ranged from 56-98%.” 32 These researchers also noted however

that the definition(s) of appropriate were themselves imprecise enough to influence such wide ranges.

Within a maternal-child telephone support service, such as Plunketline in New Zealand33and other

parentline services34, a different orientation, model, or mindset underpins the service and its operation.

Whereas a paediatric triage service will focus on suspected illness and parental concerns about a

symptomatic or injured child, a maternal-child telephone support focuses on parenting concerns regarding

the healthy development of the child and in supporting parents in their everyday parenting practices.



There are overlaps between such services in that parents may call a maternal-child telephone support line

with what for them is a health concern, for example, related to their baby’s poor feeding, sleeping or

inconsolable crying or their toddler’s rash, fever or earache. As Polaschek & Polaschek caution, in assessing

the nature of a call from a parent: “The distinction between physical and non-physical issues was not always

clear.”35

This research theme within the literature of autonomy and algorithms traverses both clinical studies

exploring the pragmatics of how nurses operationally use and often work around the detailed protocols

and algorithms that they are expected to use for particular callers or symptoms and more organisational

and sociological studies focused on the nature of work and call centre work in particular.36 Depending upon

an orientation towards a particular model or conceptual understanding of a telephone support service, one

person’s inconsistency or deviation from protocol is another’s flexibility or nuanced clinical judgement, and

one group’s “cookie-cutter approach” is another’s assured strategic alignment.37 The research on

algorithms and autonomy also assists in understanding the effectiveness of both guidelines and telephone

support services and the relationship between clinical and/or operational/organisational effectiveness.

Studies have described the crucial role and place of the computerised clinical assessment system or

telephone triage and advice system and other technology mediators of the caller-nurse interaction.38

Essentially, these are the systems that a provider will purchase from an IT vendor to handle the

technological side of the calls. In more modern systems, the technology will also incorporate the various

algorithms and guidelines. Nurses’ perspectives have been investigated in studies highlighting how they use

these systems and detailing implications for their disposition of calls, that is, how they triage or deal with

callers.39

Several studies described in the literature have addressed nurses’ frustrations with such software and

computer systems that are usually purchased and introduced with little or no consultation or discussion

with the nurses who will be using them.40 This top down approach to system choice and purchasing is often

the norm in relation to the introduction of most health service computerisation and technology.41

Having easy-to-use, reliable equipment, collaborative involvement in service design and training

and support may improve staff experience of using telehealth.

(Brewster et al. 2013)



6.1.3 Who uses telephone triage/support services and why

The focus of this review is concentrated on children: both paediatric triage and maternal-child telephone

support. Within general telephone helplines internationally, it is a consistent finding in the literature that

there is a high percentage of use by parents (and mothers in particular) in relation to children and

especially the younger under 5s.42

There is also a general agreement in the literature regarding those who are not accessing such services.

This tends to be people in poorer socio-economic groups and minority ethnic populations.43

Key points

Algorithmic guidelines and protocols are not wholly objective tools. They exist and work

within complex social systems. This consistent finding is important to grasp in order to

appreciate how both paediatric triage and maternal-child telephone support services work.

Algorithmic thinking and its supporting clinical guidelines and symptom protocols are more

appropriate and suited for paediatric triage where the focus is on the potentially sick or

injured child.

Maternal-child telephone support services tend to require a more counselling oriented

approach and, holistic, critical thinking where experienced professional judgment is

foremost.

Computer systems, decision support systems and guidelines are not value neutral pieces of

technology. They are part of the broader social system of the telephone service and must be

understood within this broader context.

Integrating guidelines into the call centre software has eclipsed paper based guidelines such

as books.

Key points

Parents of younger children <5 are among the most frequent users of telephone

helplines.

Their reasons for calling range across symptom and potential illness-related advice,

through more general parenting and child wellbeing advice to the need to discuss

serious and complex psychosocial child welfare issues.

Groups who should benefit from telephone support services and the greater ease of

access that they promise are often among the lowest users.



6.1.4 Your call is important to us - scripts and sincerity

The human side of telephone triage is inextricably linked to the overall dimension of service quality. The

tensions between working from a scripted guideline or algorithm and working as an autonomous health

professional, between coming across as robotic and mechanised as opposed to human and personal,

between allowing staff to improvise and respond in individual and personal ways in contrast to creating

increasingly scripted and standardised responses are all challenges faced by telephone services. The

literature consistently finds that callers value the quality and usefulness of advice and support given but

perhaps above that, they value the empathy, listening skills and human qualities of the nurse or call taker.

As found repeatedly in the Parentline evaluation: “As in our previous evaluation, they particularly valued

the listening.” 44

This aspect of service quality highlights the interconnected nature of paediatric triage and maternal-child

telephone support services. A quality children’s telephone support service must be an evidence-based

mosaic that incorporates the best of guidelines and decision support systems blended with the expert

clinical judgment and deep professional experience of the nurses responding to the calls.

6.1.5 Nurse and user perspectives

A body of studies and reports has explored the perspectives of both the nurses who provide services45 and

the parents or other service users. These provide insight into the perspectives of the people who deliver

these telephone services and those who use and receive them.46

The main challenge in telephone health services is the difficulty of accurately assessing a situation with

limited sensory input. The telephone conversation is different from face-to-face assessments as

information is gathered through a limited conversation on the phone. The assessments are often made in a

crisis and the nurse must rely on the client for information that may be inaccurate or incomplete.

47,48,49,50

In relation to child health telephone services, the conversation is usually with a parent or caregiver. When

their child is ill, many parents feel insecure and seek assistance in sorting out their child’s medical

problem.51 It can be a challenge to accurately assess the severity of the situation when dealing with an

anxious parent or caregiver.

Greenberg52 evaluated an established nurse-run telephone service in a paediatric outpatient setting. The

study found that nurses were valued for their listening and communication skills, their ability to extract

information from the caller, and their ability to impart information in a way that the particular patient

could understand.



There is no indication in the literature as to the skills a telenurse must possess. However, there appears to

be consensus that the nurse must have a minimum of three to five years’ nursing experience, preferably in

a variety of settings, as well as exceptional interpersonal skills and superior communication skills both

verbally and in writing. In addition, possessing knowledge of community resources and an ability to work

well under pressure are assets in practice.

6.1.6 Risk management

Risk, its nature and its management and safety, are the focus of a broad group of studies and related

commentary. In an increasingly risk averse wider society, the place and functions of a telephone triage or

maternal-child telephone support system are thrown into sharp relief. Political, lobby, vendor and

professional groups all appear to wish to occupy the moral high ground of risk aversion and to outdo each

other regarding who can assure the safest and most risk-free system. Within the call centres themselves, it

seems, staff and systems must try to reconcile the desire and need for safety with the unarguable

unpredictability of the work itself and the growing public expectation of universal availability and ease of

access. While the input side of this call centre equation may be increasingly regulated and prescribed, the

research suggests that the outcomes cannot be..53

Key points

Guidelines and protocols are especially important in paediatric triage services but there is a

danger that caller satisfaction and compliance will diminish if such calls are handled in a

mechanistic or robotic way where adhering to the protocols may hit the target but miss the

mark.

Over scripted responses from call handlers can alienate and irritate rather than support callers.

Telephone service users and parents in particular value the talking and listening human qualities

of the call responder, feeling that they have been speaking to a real person who genuinely

understands their issue and who can help.



6.2 Guideline evaluation frameworks from the literature

The most comprehensive evaluation framework identified in the literature for services that provide nurse

led telephone triage, care and advice for the parents of children birth to five years is the Canadian National

Initiative for Telehealth Framework of Guidelines (2003). These guidelines cover everything including

clinical standards and outcomes, human resources, organisational readiness, organisational leadership, and

technology and equipment.

The evaluation framework for practice guidelines most frequently discussed in the literature is the

Appraisal of Guidelines for Research & Evaluation (AGREE II) Framework. This framework appears to be the

gold standard for appraising clinical guidelines. However, it has not been specifically evaluated for use of

telephone guidelines.

The AGREE II Instrument was developed to address variability in the quality of practice guidelines and one

of its specific goals is to enable use by health care providers who wish to undertake their own assessment

of a guideline before adopting its recommendations into their practice. However, this instrument does not

offer the capacity to identify specific criteria for the evaluation of paediatric or well child nurse led

telephone, triage, care and advice guidelines.

There is little evidence available in the literature that indicates what constitutes a good maternal and child

health guideline for telephone triage and care. There is no current literature from an Australian

perspective. Evidence of the effectiveness of guidelines mostly exists for the medical telephone triage of

urgent physical adult and paediatric calls.

Much of this literature explores whether services can be claimed to reduce hospital admissions or if a

particular algorithm is accurately used. There is no consistent evidence that paediatric triage services

reduce emergency department or hospital visits. Evaluation of the correct use of algorithms is also mixed.

This concern is made redundant when much literature indicates that algorithms in and of themselves are

not an indicator of parent satisfaction or improved child health outcomes.

What remains of most importance are the operations that wrap around the guidelines and the users of the

guidelines. There is no evidence that use of protocols will standardise care or that algorithms always equal

quality of service provision.54

Further, Coon et al (2012) argue that there is no evidence indicating that telephone triage by consultants

reduces paediatric hospital admissions. In the most recent UK experience, General Practitioners and

emergency departments reported an increase in demand following the roll out of NHS 111.



The skills and experience of the nurse call taker appear to relate to the quality of experience of the receiver

and the quality of dispositions and referrals. Additionally, there is a significant correlation between

accurate estimation of urgency and training around use of guidelines55. In the paediatric setting Melzer

(2003) argues that the level of paediatric nurse expertise can impact on parent satisfaction.

The nursing skills derived from literature as evidence of best practice for telehealth include advanced

communication skills56active listening, active advising and call structuring and the time required to utilise

these skills. In the specific area of well child health clients need to be able to talk when in a crisis57 or to

ventilate when they have concerns58, in an interaction where they are not- judged.

Boddy and Smith (2007) note that client satisfaction in using well child telehealth was not related to the

provision of solutions, but more to the quality of care received. This correlates with the current child and

family health nurses position in Australia and New Zealand, whereby core to all consultations is the use of a

partnership approach59.

Telehealth appears to work well for clients and nurses when it is perceived as a dual triage system that

values both the support of the guide and the critical thinking of the nurse60 or when the guide is viewed as

complementary support. In this system nurses have the capacity to override or redirect the system if their

clinical judgement is not matched by the software. The use of software cannot substitute tacit nursing

knowledge.61

It seems that the more qualified and experienced the nurse call takers are, the more likely they are to

integrate the call protocols into their existent nursing knowledge. In specialist nursing areas, advanced

practice nurses have sufficient internal decision trees.62 However, while some nurses have found

computerised decision support to be inhibiting, controlling and obstructive to nursing work, they do not

want to work without it.63 Rather than being seen as aids in decision making, telehealth programs can also

be used as a basis for assessment during the exploration phase of the call.64 In telehealth, decision making

is not linear and mechanical process moving from A to B. Decision support systems were therefore of use in

specific situations but limited in day to day practice.



7. Conclusions

This review of the literature reveals that delivery of nurse-led telephone information and advice services

has expanded over the last two decades. These services offer a clinically effective and cost-effective way to

assess the needs of children and parents and provide valuable information and advice in response to

questions and concerns from parents.

The key agreements in the literature are around the themes that can impact on the development and

delivery of services. It is evident that algorithmic guidelines and protocols are not wholly objective tools;

rather, they exist and work within complex social systems. This consistent research finding is important to

grasp in order to appreciate how both paediatric triage and maternal-child telephone support services

work.

Algorithmic thinking and its supporting clinical guidelines and symptom protocols are more appropriate and

suited for paediatric triage services where the focus is on the potentially sick or injured child. Maternal-

child telephone support services, however, tend to require a more counselling oriented, holistic, critical

thinking where experienced professional judgment is foremost.

The computer systems, decision support systems and guidelines are an integral part of the broader social

system of the telephone service and must be understood within this wider context, particularly as

guidelines integrated into call centre software have now eclipsed paper based guidelines such as books.

Key Points:

In an ideal situation a telehealth triage system would be used to complement the

specialist knowledge and experience of an advanced practice nurse.

It would be marked by ease of use and flexibility.

Nurse call takers require clinical expertise in the specialist area (general nursing and

child and family health nursing), expertise in advanced communication, and telehealth

system operation.

The call disposition is enhanced where education and training is provided around the

telehealth system, and nurses are allocated sufficient time to engage with clients.



Although guidelines and protocols are especially important in paediatric triage services, there is a danger

that caller satisfaction and compliance will diminish if such calls are handled in a mechanistic or robotic way

whilst adhering strictly to protocols. Over scripted responses from call handlers can alienate and irritate

rather than support callers. The literature is in agreement that telephone service users and parents in

particular value the talking and listening human qualities of the call responder, feeling that they have been

speaking to a real person who genuinely understands their issue and who can help.

Whilst analysis of the literature reveals an extensive body of knowledge in the field of telephone triage,

there is little in the academic or grey literature about the existence, availability and costs of the actual

guidelines themselves. This demonstrates a clear gap in the research on this topic.



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