Impact of a nurse triage system on junior doctors' workload

We were interested in the article by Moore & Willmott (Psychiatric Bulletin, October 2004, 28, 368-370) that discussed the impact of a nurse triage system on junior doctors’ workload. We were involved in piloting a very similar nurse triage system at Solihull Hospital, which has a psychiatric unit based in a district general hospital.

At the time of our study the senior house officer rota was a 1:6 ‘ on-call’ system covering the four in-patient wards, accident and emergency and general practitioner referrals, and liaison referrals within the hospital.

The nurse triage system was introduced at the beginning of February 2004. Nurse practitioners were to be the first point of contact for all referrals and ward calls in order to offer advice, screen referrals and assist the doctor with certain administrative work. During the trial a nurse practitioner was not present for every on-call shift, which therefore allowed us to evaluate the impact of a nurse practitioner on junior doctors’ workload. Between 17 February and 17 May 2004 the six senior house officers recorded the time and nature of the calls they received and whether there was a nurse practitioner working with them. During this period there were 44 on-call shifts with a nurse practitioner present, 39 where there was not and 8 where it was not recorded.

The average number of calls received by the junior doctors was not significantly different with a nurse practitioner present (7.25) or without (6.76) (t-test P=0.53). The type of call received was recorded in four categories: referrals/advice, admissions, psychiatric ward calls and inappropriate calls (wrong mental health team/specialty etc.). The type of call received did not differ significantly depending on whether or not a nurse practitioner was on duty (t-tests, P=0.93, P=0.61, P=0.51, P=0.17, respectively). When a nurse practitioner was present, junior doctors did not receive 5 h continuous rest (the minimum required to be compliant for an ‘on-call’ rota under the new deal) for 34% of on-call shifts, compared with 26% when the junior doctor was working alone. There was, however, no significant difference between these results (χ² P=0.10).

Our results would appear to confirm the findings of Moore & Willmott that a nurse triage system had no significant impact on reducing junior doctors’ workload. We felt though that having an experienced nurse on duty offered junior doctors support during assessments, improved multidisciplinary relationships and provided specific guidance for those who were newly appointed. However, these benefits must be balanced against the risk of trainees missing out on essential learning experiences in acute psychiatry as described in the recent letter by Dixon (Psychiatric Bulletin (Correspondence), November 2004, 28, 426).

A carefully planned nurse triage system in fact could not only be a valuable part of service provision in the light of changes in junior doctors’ working hours, but also lead to an overall improvement in care received by psychiatric patients out of working hours. Clearly there needs to be further evidence published to ascertain if a nurse triage system would be a viable working arrangement.