How do triage-call-handlers in unscheduled care navigate their discretional space in machine-mediated and rule-based telephone interactions?

Problem

Telephone triage in unscheduled care occupies a key position in regulating access to services. Triage-call-handlers come from a variety of occupations. Their interactions with callers are scripted by algorithm. They have various degrees of liberty in choosing the appropriate algorithm and/or overriding the algorithm. Adherence to the algorithm can be part of key performance indicators. Tensions exist between listening to the caller and following the rule-based conversation structure. Effective and efficient triage conversations ought to assist in "getting it right first time" and have to address the complexity of presenting problems incl. child health, end-of-life-care, mental health and multiple morbidities. This study explores how call handlers deal with this problem in their occupational contexts. This includes different software systems and different organisational settings. They all have in common that complex situations have to be approached using a technology-mediated interface.

Approach

We use a mixed methods qualitative research design with semi-structured in-depth interviews and non-participant ethnographic field work. We contacted triage-call-handlers in the settings of Ambulance Control, NHS Direct and GP Out of Hours. There are two consecutive interviews. The first interview focuses on the occupational context and individual professional background. The second interview explores using a narrative technique emotional labour in the provision of care in triage-consultations. The research project is part of an undergraduate student research; students are trained as research assistants and learn by discovery.

Findings

The data gathering period will be in May. Consultations with call-handlers in the fields of ambulance control, GP Out of Hours and NHS Direct highlighted the themes that informed the topic guide: choice of algorithm, degree of professional liberty in potentially overriding the template, ability to do the job if the presenting problem is not adequately covered by the algorithm, emotional aspects of being remotely exposed to difficult or dramatic situations, organisational culture, supervision.

Consequences

The findings are important because increasingly technology-mediated encounters are part of primary care, particularly in the realm of resource allocation. The tension between normative and narrative, diagnostic and therapeutic conversations is in the heart of this evolution of services. Finding out how call-handlers do their job in machine-mediated healthcare encounters enables improvement of the interfaces between caller and organisation, but also call-handler and software.