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Scope of Practice - Conflicts and Controversies Study

Study Findings and Recommendations

EXECUTIVE SUMMARY
PROBLEM STATEMENT:
Telephone Triage, although rapidly emerging as a new specialty in nursing, is poorly defined and lacks the benefit of clear direction from the State Boards of Nursing. Regulatory policies, where they exist, are ambiguous at best, providing little if any guidance to the nurse engaged in this practice. Furthermore, in spite of the proposed interstate compact for mutual recognition in nursing, inconsistency among the states complicates the role of the Telephone Triage nurse who is practicing across state lines.

APPROACH:
A survey of the 50 State Boards of Nursing was conducted for the purpose of identifying existing Board policies and opinions that guide the practice of Telephone Triage. A primary goal of the study was to investigate various positions and opinions of the state boards of Nursing regarding Telephone Triage practice and to define the extent of inconsistency among the states. A second goal was to identify established policies that might serve as models for other states.
FINDINGS:
A wide degree of variability exists among the State Boards of Nursing relative to statute, rules and regulations, and practice standards addressing the practice of Telephone Triage. Nurses engaging in this specialty are doing so in a highly ambiguous milieu in which the language of Nurse Practice Acts is silent on most related issues, and the few standards that do exist are poorly understood and provide little meaningful direction. Where regulatory standards do exist, they are inconsistent among the states and consequently, nurses engaged in Telephone Triage practice might be unaware that standards differ from state to state.

Significant controversy exists in how various Boards view the recommendation of medications according to protocol. A slight majority of states held that it is within acceptable practice for RNs to recommend both prescription and over the counter drugs, with a significant minority dissenting on both counts. While some viewed practice guided by protocols as implementation of physician's orders as appropriate to the patient situation, other states felt that nurses recommending medications according to protocol were engaged in the act of medical diagnosis. A small number of states felt that medications could be recommended according to protocol, but only under special circumstances or only if patient-specific. Conversely, a significant majority of the respondents felt that it is not acceptable for LP/VNs to recommend medications according to protocol under any circumstances.

Great controversy also exists regarding the role of LP/VNs in Telephone Triage. Lack of a consistent definition of Telephone Triage made this question difficult for most Boards to answer with confidence. While many states allow LP/VNs to practice "under supervision", it is the responsibility of the employer to determine the complexion of this supervision. Several Boards expressed concern that the only way to adequately supervise an LP/VN in this role is to monitor individual telephone conversations, resulting in unnecessary duplication of personnel .

DISCUSSION:
These findings are significant in that they are inconsistent with current practice. While formal call centers primarily utilize RNs in delivery of care, the majority of telephone triage is being done in informal settings such as doctor's offices. In many of these settings, it is known that most of the triage calls are managed by LP/VNs and/or unlicensed assistive personnel (UAPs). According to most states, triage (involving assessment) of patients by telephone exceeds the scope of practice of the LP/VN. Telephone assessment of patients by personnel who are not trained or licensed to do so is imprudent due to the complexity of patient management under conditions of extreme uncertainty compounded by limited sensory input. At the same time, the prevalence of delivery of care by telephone is growing rapidly, and greater numbers of nurses will be required in the near future to "man the telephones". Even if employers agree that RNs are the appropriate professionals to deliver this care and are willing to pay for them, it is likely that a shortage of RNs will exist to fill these roles, especially in some rural settings. Because the complexion of patient care delivery is changing, it is essential that nursing policy makers be flexible and think "outside the box" in establishing regulations which may serve as guidelines, rather than barriers, for nurses to follow in the provision of safe and effective care by telephone .

RECOMMENDATIONS:
As is often the case, the practice of Telephone Triage is preceding the development of standards to support this practice. Development of uniform standards of care in Telephone Triage that are supported by clear direction from the State Boards of Nursing would be advantageous.  This dialogue should endeavor to address recommendations for policy development including but not limited to:
  • a standard, descriptive definition of Telephone Triage,
  • standard language relative to this practice,
  • the role of the nurse in applying standardized protocols under the  direction and supervision of a physician or practitioner,
  • the role of the nurse in implementation of protocols which direct recommendation of legend or over-the-counter drugs, and
  • who can do Telephone Triage and under what circumstances, including clarification on nursing limitations (RN and LP/VN) in the context of Telephone Triage.
In summary, dialogue is critically needed to address ambiguity in policy and inconsistency among the State Boards of Nursing relative to the practice of Telephone Triage.
PROPOSED DEFINITION OF TELEPHONE TRIAGE (Revised 11/00):
Telephone Triage is an encounter with a patient/caller in which a specially trained, experienced nurse, utilizing clinical judgment and the nursing process, is guided by medically approved decision support tools (protocols), to determine the urgency of the patient's problem, and to direct the patient to the appropriate level of care. This plan of care is ideally developed in collaboration with the caller and includes patient education/advice as appropriate and necessary.