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Mental health triage what skills are needed? Mental health triage--nurses have to be experienced practitioners with a range of skills to ensure patients get the services most appropriate to their needs.

Triage is not a new concept--it's based on the French verb "trier", meaning to separate, sift or select. (1) In health care it is a concept used to prioritise a person's need for treatment: immediate, less urgent or non-urgent attention. It can be seen as a process to manage the difference between demand for, and available resources within health services. (2) While triage has been happening in emergency rooms and on battlefields for years, the adoption of this concept in mental health is somewhat more recent. A cursory search on OVID Medline revealed only one referenced article earlier than 1975.

In contemporary mental health care, triage has become a necessity, as only the most at-risk people can access inpatient treatment. (3) This has come about due to changes in treatment philosophy, eg treating people in the least restrictive environment and the associated focus on enhanced community care.

Single point of entry

Within mental health, triage is a clinical process conducted by a mental health clinician to prioritise the appropriate service for the consumer. This is based on the consumer's needs, and associated risk, disability or dysfunction. To do this effectively, the triage service needs to operate as the single point of entry (SPOE) for the mental health service in that region. Ideally, it provides a rapid and consistent response to ensure every referral is examined in a consistent manner and the resources needed are based on the outcome of the triage. In general, the SPOE provides initial advice, takes referrals for adult (and sometimes specialist) mental health services, forwards other referrals to the appropriate service, books assessments for adult community teams, and forwards emergency needs to the local crisis or psychiatric emergency team (5) (see Figure 1).

In reality, every referral gets briefly screened to ascertain if it needs immediate follow-up (crisis triage), or can be followed up over a longer period (non-urgent triage). Every mental health service will have different ways of dealing with urgent and non-urgent cases --from having different clinicians to deal with each, through to having all clinicians working with non-urgent cases when not involved in urgent/crisis cases.

To make a decision about the most appropriate response to a referral, the triage clinician needs information. This can be obtained from a variety of sources--the consumer and/or their family, as appropriate, from historical health information available and easily accessed, and from other treatment providers, eg a community mental health nurse or a GP.

In New Zealand there is a health information privacy code which governs practice onsharing health-related information between health service providers. (6) The code allows for sharing health information with services that provide health care, or are about to provide health care to an individual. Ideally, this is done with the consent of the person concerned, but if this is can't be obtained, then the information can still be shared. This is very helpful for making a timely assessment of the type of mental health service a person may need.

Because of the size of some mental health regions, the most efficient way for an initial contact and enquiries is via the telephone. However, this has some disadvantages. If a person contacting mental health services is in crisis--ie a state of psychological disequilibrium (7) --getting clear and concise information from them could be problematic. This, in itself, adds to the overall clinical information for the clinician. If time allows, it is helpful to obtain as much third-party information as necessary to provide an overall impression.

Phases of telephone triage

The phases of a telephone triage in mental health can be identified sequentially: the opening; assessment and examination; planning and action; and termination. (8) For each of these phases, certain tasks and associated skills are necessary (see Table 1).

A group of researchers has suggested the telephone is a reasonable method for assessing psychiatric disorder, as their research concluded there was no significant difference between telephone or face-to-face assessments. (9)

When faced with limited time to assess clinical need, the key factors of risk, distress, and disability/loss of function should be prioritised.

In reality, there are a variety of factors outside risk, distress and disability which influence an eventual decision. These include prior knowledge and experience with the person concerned, the location of the person, the source of the contact (another professional, family or third party) (10) and the resources available for an immediate, urgent or non-urgent response. There needs to be a balance in the time between triage and more in-depth contact. Achieving this balance is a significant burden for the triage clinician because, as with all situations involving people in distress, the dynamics associated with the risk of an untoward outcome are fluid, and cannot be entirely mitigated against. Also, the other parts of the response system--first responders such as police/ambulance, the crisis team, emergency department, GPs and psychiatric medical personnel--may place less importance on the triage clinician's risk assessment/urgency, preferring to re-assess the situation for themselves.

It may be helpful to consider the process using the concepts of the critical incident response strategy--preparation, detection, and response. (11) The multiple players in this process fully understand each other and train together, so errors in communication and understanding are minimised to the greatest extent possible.

The Government promotes an inter-agency coordination system for critical incidents, the New Zealand Coordinated Incident Management System (CIMS). (12) The key purpose of CIMS is to establish common structures, functions and terminology among the various agencies involved in responding to major incidents. These concepts can be applied at a local level to enhance response following mental health triage. The main principles are common structures, roles and responsibilities; shared terminology; integrated coordination; coordinated planning; information sharing; and resources. (12) Joint exercises where the various services and agencies run through different scenarios together--possibly based on situations that did not end as well as they could have--would be a good quality assurance activity.

The need to respond to urgent/crisis situations within an appropriate time is common to all mental health services; however, the timing of that response can differ. There are various mental health triage scales and each is different, including the response timeframes. (4,13,14,15)

One of the key functions of triage is to ensure the appropriate level of response for the level of need. This is echoed in recent government position papers, such as Blueprint II, which states: "Organised mental health and addiction responses: Recovery and resilience focused responses provided by the health and other sectors and covering self-care, primary, community and specialist settings."

So, the triage clinician has a key role in determining that primary-level needs are directed to primary-level services. However, these services face resource constraints and there are other barriers, eg transport to the service where a person has no local primary-level mental health service, or money, if a co-payment is needed for the service.

The Government has steadily reduced funding to key agencies like Relationships Aotearoa and Lifeline, (17,18,19,20,21) which, unless addressed, will eventually shift the primary mental health burden back to secondary mental health services. Unmet need at the primary level evolves into secondary-level mental health need, creating even greater demand for expensive clinical intervention.

Adequately prepared nurses are able to conduct mental health triage. (22) Various writers have identified the skills and knowledge needed for this role. These include telephone interviewing, history taking, problem identification, risk assessment, crisis intervention, documentation, (23,24) mental status examination, the ability to work within ethical and professional boundaries--especially around confidentiality and privacy, (22) formal training and supervised experience. Because of the variety of needs and issues presented by people contacting, or being contacted by, mental health triage clinicians, strict response protocols would be impossible. (22) The staff in triage roles have to be experienced and have "internal decisions trees". (22)

A formal training programme needs to include information on the underlying principles of telephone assessment; professional issues such as confidentiality, accountability and legal considerations; communication skills; assessment skills; strategies for dealing with abusive callers, intoxicated people, silent callers and parasuicidal callers; debriefing; audit processes and quality assurance. (26)


Mental health triage has become a necessary component of mental health care. The limited resources available at the secondary/tertiary level have to be allocated so the most unwell people, or the most at risk, are given priority. Due to distances in New Zealand, the most economical way to undertake mental health triage is by telephone. Any experienced mental health clinician, who has been adequately prepared through a well-developed induction/education programme, should be able to undertake this role.

* References for this article are available from the co-editors.

Brent Doncliff, RN, MN (hons), is a mental heath triage nurse with the Waikato District Health Board.

Table 1: Tasks and skills involved in mental health telephone
triage. (8)

Opening           examination       Planning/action   Termination

Tasks             Tasks             Tasks             Tasks

* Introduction    * Determine the   * Determine       * Ensure caller
                  problem           important needs   aware of plan
* Gather
demographics      * Identify        * Develop plan    * Documentation
                  current           of action
* Establish       presentation                        * Referral on
rapport           and risks         * Assign triage
                                    category          Skills
Skills            Skills
                                    * Team            * Documentation
* Encouraging     * Open-ended      discussions
tone and          questioning
mannerisms                          * Inter-service
                  * Mental status   collaboration
* Active          examination
listening                           Skills
                  * Risk
* Providing       assessment        * Clinical
reassurance and                     communication
                                    * Problem
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Title Annotation:viewpoint
Author:Doncliff, Brent
Publication:Kai Tiaki: Nursing New Zealand
Date:Sep 1, 2015
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