A DSN telephone audit: one way to manage telephone work

Telephone contact between patients and healthcare professionals, and DSNs is an established and integral part of the DSN workload. This has previously been described by Wilbourne and Wilson (1996). The National Service Framework for Diabetes (DoH, 2001) states that patients should have access to high quality care and support and this can certainly include telephone access to healthcare professionals including DSNs. However, as Johns (1997) comments telephone contact work is often unrecognised and is a hidden area of the DSN workload.

Miles (2002) describes the stress of increasing DSN workloads, which is recognised by many DSNs. She describes DSNs as being ‘slaves to the telephone’, having their work interrupted by telephone calls throughout the working day. Wilbourne and Wilson also (1996) noted that the impact of telephone calls on DSNs workload was significant.

The Airedale experiences
Our experiences at Airedale General Hospital are very similar to those described by Miles (2002). As a DSN team, we realised that we received calls throughout the day and that DSNs are the first contact for anything related to diabetes. Many telephone calls from patients and healthcare professionals were appropriate. However, other telephone calls relating to appointment queries or requests for medical notes were clearly not.

Objective of the audit
Our aim was to review the number and type of telephone calls to the DSN office. We also wanted to assess the amount of time spent on processing and dealing with telephone calls to our office and the impact this made to our clinical workload.

Prior to our audit, the DSN office had three telephone lines. Two of these accepted incoming calls and were attached to answerphones. These three telephone lines were shared by five people (three DSNs, the ward diabetes liaison nurse and the senior healthcare support worker). The phone lines were used for both incoming and outgoing calls. Although we had two answerphones, we had no agreed standards or policies for answering calls. All members of the team were frustrated by the constant ringing of the telephones, as it interrupted our planned work and meant having to access more than 10 messages at a time from the answerphones.

Initial audit
In conjunction with the clinical effectiveness unit, a telephone audit form was devised to record the type and amount of all incoming calls, the relevance of the call to the DSN office and the action taken by the DSN after receiving the call. This audit form was piloted for a week then amended to produce the final audit form.

The initial audit took place over 2 weeks in 2001. All completed audit forms were then processed by the clinical effectiveness unit. Initial results are summarised in Table 1.

Changes to practice
After reviewing our results, the DSN team made the following changes to practice in relation to telephone calls:

• A designated incoming direct telephone line with an answerphone was used to receive incoming calls only.
• Each DSN had their own outgoing line but only the answerphone line telephone number was given to patients and other healthcare professionals.
• An answerphone only service was initiated with an agreed standard for accessing answerphone messages (messages were accessed at four hourly intervals up to 4pm each day – Figure 1).
• A specific answerphone message which, as well as explaining how messages would be accessed, also gave the direct line numbers for diabetes centre appointments and diabetes paediatric services. The message also directed patients to contact their GP if they required urgent advice or treatment.
• All the above changes were advertised via the centre newsletter and by the DSN who explained the changes to practice at every patient contact.

Two other changes took place at the same time which impacted on DSN practice. Appointments for diabetes clinics, which had previously been organised by the general outpatients department, were centralised within the diabetes centre and organised by a newly appointed diabetes centre appointments co-ordinator. In addition, the hospital blood glucose meter contract was awarded to a meter company which offered much more support to ward nurses. The company provided a helpline number which ward staff were encouraged to use for any problems they encountered.

A second audit
Once the answerphone service for incoming calls was established, we decided to re-audit 6 months later.

The second audit took place over two consecutive weeks and used the same audit form. The only difference from the first audit was that the audit forms were completed after the answerphone message had been recorded by the DSN. Results from the second audit are summarised in Table 2.

Results from the second audit were very similar to those from the initial audit. There was a reduction in the total number of calls but it is difficult to draw any conclusions from this as the reduction in calls could have been due to a variety of reasons including:

• Wanting to speak to someone personally.
• Not wanting to leave a long message.

Other changes to practice as a result of the second audit
We purchased telephone headsets for all the DSNs as a result of a visit to a NHS call centre where it was noted that all nurse advisors used headsets. The telephone headsets enable us to have a telephone conversation but allow us to be ‘hands free’, so enabling us to access computer results or nursing notes and write and record conversations at the same time.

Our results were presented to the other members of the diabetes team and to our immediate line managers. This helped immensely in raising awareness of the type and amount of work generated by incoming telephone calls to the DSNs. With the support of our managers and the diabetes team, we were able to secure a post for a DSN receptionist. The receptionist is based in the diabetes centre and is able to access all calls to the DSNs, redirect calls as appropriate and take relevant messages for the DSNs. The system is proving to be popular with patients and healthcare professionals and allows us to work in an office not interrupted by incoming calls all the time. In addition a voicemail system is in operation when the receptionist is not on duty. We plan to re-audit our telephone work again, once our new system is established.

Discussion
The change to an answerphone only service was not universally popular with patients or other healthcare professionals, according to some of the comments received. However, it can be argued that very few patients obtain instant access to their GPs or other healthcare professionals without either leaving a message via a receptionist or answerphone. In addition, as a DSN team we feel that our role is not to offer an emergency advice service but to offer support in a proactive rather than a reactive role.

The percentage of ‘appropriate’ calls from patients and other healthcare professionals stayed constant at about 67% in both our audits. This indicated the need for patients to be able to contact the DSNs. On average, approximately 70-120 minutes were spent processing incoming calls per day. These findings appear similar to those from previous studies (Johns,1999; Wilbourne and Wilson, 1996).

As a team, we felt the answerphone message should be clear and appropriate. We also believed it was important for patients and other healthcare professionals to know that all messages would be accessed on a regular basis and calls returned within the same working day.

The headsets have been extremely useful in helping us manage our telephone work plus reduce the risk of neck strain. At a cost of approximately £80 each, we believe this has been very cost effective.

Conclusions
Our audit results demonstrated the number of calls and time spent by DSNs on processing incoming calls. 

Telephone work is an important and integral part of the DSN workload which cannot be planned for in advance. We found that by implementing small changes to our practice in answering incoming calls, our workload became easier to manage and in turn created a more positive effect in relation to telephone work.

Acknowledgements:
We appreciate the help of Airedale NHS Trust Clinical Effectiveness Unit with this audit. We are also grateful for the support of the diabetes centre team and trust management in enabling us to implement the changes to our service.