title: The impact of using computer decision-support software in primary care nurse-led telephone triage: interactional dilemmas and conversational consequences.
abstract: Telephone triage represents one strategy to manage demand for face-to-face GP appointments in primary care. Although computer decision-support software (CDSS) is increasingly used by nurses to triage patients, little is understood about how interaction is organized in this setting. Specifically any interactional dilemmas this computer-mediated setting invokes; and how these may be consequential for communication with patients. Using conversation analytic methods we undertook a multi-modal analysis of 22 audio-recorded telephone triage nurse-caller interactions from one GP practice in England, including 10 video-recordings of nurses' use of CDSS during triage. We draw on Goffman's theoretical notion of participation frameworks to make sense of these interactions, presenting 'telling cases' of interactional dilemmas nurses faced in meeting patient's needs and accurately documenting the patient's condition within the CDSS. Our findings highlight troubles in the 'interactional workability' of telephone triage exposing difficulties faced in aligning the proximal and wider distal context that structures CDSS-mediated interactions. Patients present with diverse symptoms, understanding of triage consultations, and communication skills which nurses need to negotiate turn-by-turn with CDSS requirements. Nurses therefore need to have sophisticated communication, technological and clinical skills to ensure patients' presenting problems are accurately captured within the CDSS to determine safe triage outcomes. Dilemmas around how nurses manage and record information, and the issues of professional accountability that may ensue, raise questions about the impact of CDSS and its use in supporting nurses to deliver safe and effective patient care.
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK. Electronic address: Jamie.murdoch@uea.ac.uk.
authors.forename: Jamie
authors.initials: J
authors.lastname: Murdoch
authors.affiliation: Centre for Academic Primary Care, School for Social and Community Medicine, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK. Electronic address: Rebecca.Barnes@bristol.ac.uk.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Barnes
authors.affiliation: Plymouth University Peninsula Schools of Medicine and Dentistry John Bull Building, Research Way, Plymouth, Devon PL6 8BU, UK. Electronic address: jillian.pooler@plymouth.ac.uk.
authors.forename: Jillian
authors.initials: J
authors.lastname: Pooler
authors.affiliation: School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK. Electronic address: V.Lattimer@uea.ac.uk.
authors.forename: Valerie
authors.initials: V
authors.lastname: Lattimer
authors.affiliation: Primary Care Research Group University of Exeter Medical School, Room 106, Smeall Building, St Luke's Campus, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK. Electronic address: E.Fletcher@exeter.ac.uk.
authors.forename: Emily
authors.initials: E
authors.lastname: Fletcher
authors.affiliation: Primary Care Research Group University of Exeter Medical School, Room 106, Smeall Building, St Luke's Campus, University of Exeter, Magdalen Road, Exeter EX1 2LU, UK. Electronic address: John.campbell@exeter.ac.uk.
authors.forename: John L
authors.initials: JL
authors.lastname: Campbell
mesh_terms: D020000:Decision Support Systems, Clinical; D003661:Decision Support Techniques; D006801:Humans; D009723:Nurse-Patient Relations; D059017:Primary Care Nursing; D012017:Referral and Consultation; D012984:Software; D013689:Telephone / Q000295:instrumentation; D016896:Treatment Outcome; D014218:Triage / Q000379:methods*
keywords: Computer decision-support systems; Conversation analysis; Multi-modal analysis; Nurse–patient interactions; Primary care; Telephone triage/consultations; UK