Nurses’ Perceptions of Telephone Triage in Child and Adolescent Psychiatric Services – An Enhanced Critical Incident Technique Study

Abstract In Sweden, units managed by nurses specialised in counselling and telephone triage, have been developed within the Child and Adolescent Mental Health services (CAMHS). This study has a qualitative design and illuminates the nurses’ perceptions of what helps or hinders their assessments and telephone triage. The Enhanced Critical Incident Technique was utilised, eight nurses were interviewed in depth, to identify factors influencing triage. The study is the first to provide a comprehensive description of helpful and hindering factors while performing telephone triage. It illuminates telephone triage in Swedish CAMHS settings and provides insights how to enhance and implement this practice.


Introduction
Over the past decade there has been an increased incidence of children and adolescents who experience mental health problems, both internationally and in Sweden (Kieling et al., 2011;Racine et al., 2021;Sjöström et al., 2023).In addition, the higher incidence of children diagnosed with depression and/or neurodevelopmental disorders, has caused a significant surge in children requiring specialist care and receiving medical treatment (Rydell et al., 2018;Skurtveit et al., 2018).This increasing need poses a challenge to healthcare services, resulting in long periods of waiting for help and care (Lay, 2006).Recent studies indicate that an even higher demand for specialist care is to be expected, as depression and anxiety in children worldwide have further increased in the wake of the COVID-19 pandemic (Racine et al., 2021).In response to the growing demand, ways to improve care are required, resulting in the development of different models for assessing and triaging mental health problems and new ways of reaching those in need (Kazdin, 2019;Lay, 2006).
In Sweden, the Child and Adolescent Mental Health Services (CAMHS) (Barn-och ungdomspsykiatri [BUP], in Swedish) are managed through 21 regional county councils.These councils are politically responsible for the public healthcare system including mental health services regarding the assessment, diagnosis and treatment of children and adolescents.According to the WHO adolescence is the phase of life between childhood and adulthood, from ages 10 to 19.It is a unique stage of human development and an important time for laying the foundations of good health as the adolescent experience rapid physical, cognitive and psychosocial growth (World Health Organization, 2023).The regulatory system, in Sweden, defines a child as an individual from birth to reaching the legal age of 18 years.However, health care makes a distinction between children, aged 0-12 years and adolescents aged 13 < 18.Within CAHMS adolescents are referred to the adult psychiatric services at age ≥ 18.
A crucial step in the CAMHS care chain is a high quality, evidence-based model for assessing the child's need of care, assuring patient safety.Therefore, in the last decade, several regions in Sweden have developed specialised units, often referred to as 'One-Way-In units' , OWI units (En-Väg-In, in Swedish), in which registered nurses assess the situation, perform triage and offer counselling via telephone, prior to a physical visit to the CAMHS.The regional residents reach the OWI units through one specific telephone number, regardless of which municipal area of the region they reside in.
The concept of triage originates from the French word trier and entails the process of sorting patients according to their need of care (Robertson-Steel, 2006).It was initially designed in the late eighteenth century, as a way of handling large volumes of wounded soldiers, related to acts of war.Based on the assessment of the injuries, where the patients' need of care was labelled as 'immediate' , 'urgent' or 'non-urgent' , a system for prioritising was developed.Triage has since been incorporated in emergency healthcare worldwide, as a way of ensuring that those in greatest need receive care first (ibid.).
Mental health telephone triage, primarily for adults, has developed over the past two decades, with the purpose of providing accessibility to psychiatric care, and is focused on assessing and managing acute psychiatric crises, identifying early signs of mental illness and providing an accurate level of care (Kevin, 2002;Lay, 2006;Sands et al., 2012aSands et al., , 2012b)).
Registered nurses and specialist nurses operate the OWI units, which are open during business hours.They offer counselling to guardians concerned about the well-being of their children and adolescents, as well as assessing and prioritising the need of further contact with the CAMHS (Mission Mental Health, 2019).School nurses or others concerned about the mental health of a child, as well as children or adolescents themselves, are welcome to call, but contact is primarily initiated by guardians.Contact is also established by way of digital self-referrals by guardians, regarding younger children.Once the child turns 13 and becomes an adolescent, guardians are excluded from writing self-referrals for the child.The digital self-referral system is connected to other digital services, including access to medical records, and making appointments and renewal of prescriptions.The health care authorities have decided that guardians should not have access to these functions on their children's behalf past the age of 13, for confidentiality reasons.This effectively means that adolescents are allowed to interact with health care services, without their guardian's knowledge and consent, regarding for example sexual health issues, birth control medication or CAMHS.Guardians are allowed to call the OWI-unit and engage with CAMHS on their adolescent's behalf but are only allowed access to the adolescent's medical charts with their consent.Hence, adolescents must write their own digital self-referrals.When triaging, the OWI-nurses initiate the assessment using an open question regarding the nature of the call and assess the situation.If this initial assessment does not indicate mental health problems the nurses give general advice e.g. to seek school counsellor or social services.When further assessment is deemed appropriate a structured interview guide covering important life-course events is used before providing contact with the CAMHS on primary or specialised level.As a complementary tool, the nurses use the Brief Child and Family Phone Interview form (BCFPI) (Cunningham et al., 2009).The BCFPI is computer-assisted and assesses the behavioural and emotional problems of children and adolescents, as described by their caregiver.It is a standardised screening tool, well suited as an intake interview, screening for major psychiatric disorders and additionally providing a notion regarding the guardian's well-being (Andersson et al., 2018;Cooke et al., 2013).The BCFPI is sent to the guardians via a digital link, and the guardians read the questions and respond.This requires Swedish language skills, as the OWI units currently do not utilise the English version.At present, no similar self-screening procedure is used for adolescents.
While working within the CAMHS, nurses need to balance the person-centred care perspective with the family-centred care perspective, to meet the needs of both child and guardian (Coyne et al., 2018;Sahlberg et al., 2020).The interpersonal aspects are vital for psychiatric nurses, which is why Hildegard Peplau's theory of interpersonal relations in nursing, focusing on the interaction between individuals, is useful (Gastman, 1998).It provides comprehension of the process of building alliances in nursing, emphasising that nursing is a task that should be performed with rather than to the patient (D' Antonio et al., 2014).The nurses at the OWI units operate within Swedish healthcare laws, rules and regulations and are required to consider the UN Convention on the Rights of the Child since it became Swedish law in 2020 (SFS 2018(SFS :1197(SFS , 2018)).
The concept of telephone triage is a relatively new phenomenon within the CAMHS, and despite extensive database searches, no studies specifically aimed at telephone triage within the CAMHS were found.A few studies concerning mental health telephone triage of people of all ages were identified (Kevin, 2002;Sands et al., 2012a;2012b), as well as studies regarding the use of telephone triage in other fields of medicine (Purc-Stephenson & Thrasher, 2010;Roivainen et al., 2020), where this seems to be a growing practice.Against this background, research needs to be conducted to understand the providers' experiences of the CAMHS telephone triage.This study is consequently valuable, as the results might reveal difficulties related to telephone triage or point to areas in need of further development and improvements.Since there is an increasing demand for CAMHS assessments and the nurses at the OWI units receive a wide variety of calls, understanding the OWI triage experience is relevant.The aim of this study was therefore to illuminate the nurses' perceptions of what might help or hinder their assessments of psychiatric problems in children and adolescents in telephone triage.

Method and material
The present study has a descriptive qualitative design, utilising Enhanced Critical Incident Technique (ECIT) (Butterfield et al., 2009).ECIT is a relatively new methodology, evolved from Critical Incident Technique (CIT).The psychologist John Flanagan was the first to scientifically construct and describe CIT, originally developed during the Second World War as a tool for understanding why pilots in training failed and were eliminated from the programme (Flanagan, 1954;Viergever, 2019).Flanagan studied the pilots' retrospective descriptions of the failure or success of a mission, by analysing the events/critical incidents that had occurred and the actions the pilots had taken, and this resulted in improved methods for selecting pilots (Flanagan, 1954;Fridlund et al., 2017).CIT is considered a suitable qualitative method for research in healthcare and nursing, as it is specifically focused on the participants' perspectives.When used in studies aimed at nursing practice, it allows the participants to describe, reflect on and identify the outcomes of practice (Keatinge, 2002).CIT is also effective in exploring helping or hindering factors, while providing good quality healthcare (Butterfield et al., 2009;Viergever, 2019), and the modification, i.e.ECIT, was considered suitable for this study.The original CIT method consists of five steps: determining the general aim of the activity to be studied; planning and specifying the settings; collecting and analysing data; interpretation of the data; and presentation of the results.Additionally, the enhancement of the method, ECIT, contains a contextual question intended to provide background information on the studied activity, and a 'wish-list' question regarding what the informant considers might have been helpful during the activity (Butterfield et al., 2009).In both CIT and ECIT, the results are presented in tables of categories that include an account of the number of participants having endorsed the findings.Categories need to be supported by at least 25% of the participants to be considered viable (Butterfield et al., 2009).To exemplify the result, citations are added to elucidate the findings and the problems that occur during telephone triage.
In this study, the activity of interest consisted of the nurses' assessments during telephone conversations with guardians and children or adolescents, and the critical incidents (CIs) were the different factors that affected the assessment and triage.Because face-to-face interviews are described as the most satisfying method in ECIT, this method was chosen for collecting data (Butterfield et al., 2009).Kemppainen (2000) emphasises that the interviewer using CIT should be familiar with the aims and objectives of the action being studied for the results to be useful and effective.The authors of this study have not worked at an OWI unit but have sufficient understanding of the process due to extensive experience of working within the CAMHS and adult psychiatric services.
The present study was conducted in accordance with the Declaration of Helsinki (World Medical Association Declaration of Helsinki 2018) and ethically approved by the Board of Ethics at Malmo University (Reg.No. 2021/41).The participants consisted of a purposeful sampling (Palinkas et al., 2015) of nurses working within an OWI unit in southern Sweden.Following formal approval from the director of the CAMHS and the OWI unit manager, the nurses received verbal and written information about the study and the terms of participation.Eight nurses volunteered (all female as no male nurses were currently employed), gave both oral and written informed consent.Inclusion required that the nurse had been working with telephone triage for at least three months.The nurses' work experience was mean 18 years (range 4 to 40 years), and their experience at the OWI unit was mean 2.5 years (range 8 months to 5 years).Four of the eight nurses had at least one advanced degree in specialist nursing.The background data of the nurses are not described in further detail due to confidentiality reasons.

Data collection and analysis
Data was obtained through semi-structured interviews, using an interview guide inspired by Barrett-Wallis and Goodwill (2020) and Butterfield et al. (2009).A 'wish-list' question, aiming at capturing the participants' perceptions of what might have facilitated their assessments, was included (Butterfield et al., 2009).In ECIT, the questions are specifically aimed at enabling the informant to remember incidents in as much detail as possible and at encouraging reflections on the meaning of the critical incidents to the participant (ibid.).
A total of eight nurses were interviewed in Swedish by the first author.The interviews took place at the OWI unit, were digitally recorded, and lasted 45-82 min (mean 65 min).The interviews started with demographical questions covering education and work experience.The participants then described their work with telephone triage to provide context.Next, the participants were asked to recall telephone triage with guardians where they had found it easy to assess the child's status and need of mental health services, resulting in triage to the CAMHS.There were no limitations regarding the number of incidents; rather, the participants were encouraged to recall as many as they desired until they had exhausted their examples of easy assessments.Every example was thoroughly discussed to identify the helping factors/CIs and explore their meaning to the participant.When the participants felt they had exhausted their examples, they were asked to describe general factors that helped their assessments.If a new factor surfaced, the participants were asked to give an example of an incident containing that factor, thus giving it meaning and context.This was done to ensure that as many factors as possible were discovered.After exhausting the helping factors, the process was repeated, focusing on telephone triage with guardians where the participant had found it difficult to assess the child's status and need of mental health services, resulting in triage to the CAMHS.Additionally, assessments performed with children or adolescents were included, as some of the calls entailed speaking directly with them.Finally, the participants were asked to formulate what could have been helpful to their assessments, i.e. the 'wish-list' question.
Each participant was given a letter for identification, to ensure confidentiality.The digitally recorded interviews were transcribed verbatim and analysed using the ECIT methodology to identify factors/CIs affecting assessment and triage (Butterfield et al., 2009).The transcripts were carefully read through several times to identify helping and hindering factors or 'wish-list' items.In accordance with the recommendations by Butterfield et al. (2009), the first interview was analysed and followed by the analysis of two randomly chosen interviews.The factors of each interview were extracted and organised using a computerised spreadsheet that contained the helping and hindering factors as well as the 'wish-list' items, their meaning and importance to the participant and a vignette to clarify the context (Supplement 1).All factors extracted were then merged into preliminary categories, based on similarities, in a new spreadsheet.The categories were given self-explanatory titles, to easily understand the contents, and each factor was given a code, which made it easier to link it to the original transcript.The five remaining interviews were consecutively added, using the same analysing process, and factors were organised into existing categories or new categories were created.To monitor the development of categories and the degree of exhaustion, a table was created.Categories not endorsed by at least 25% of the participants were reviewed, and efforts were made to place them in an already created category when deemed appropriate.The degree of generality or specificity was considered, and some general categories were formed, but a high degree of specificity was maintained so as to convey the participants' own descriptions as much as possible.Finally, the participants' replies to the contextual question were merged into one general description.

Rigour
To achieve trustworthiness within a study utilising ECIT, Butterfield et al. (2009) suggest several credibility checks.In this study, a literature search was initially performed to explore scientific research in the field.The interviews were digitally recorded, and the material and the extraction of CIs/factors were consecutively reviewed by the second and third author to ensure interviewer fidelity and that the analysis was executed according to the ECIT method's directives (ibid.).The level of exhaustion was monitored, and following the fourth interview, no new categories emerged.The endorsement rate by the participants was carefully observed during the process.All participants reviewed their own analysed interview material and were invited to give input on whether the categories were viable and corresponded to their perceptions or not.This cross-checking did not result in any changes and no need for a second interview arose.As telephone triage is a new practice in the CAMHS, no experts, other than the participants themselves, were available to review the findings.Finally, the categories and quotes were translated from Swedish into English, checked for language conformity and proofread by an authorised language editor.

Results
This study resulted in 305 CIs/factors: 158 helping factors and 147 hindering factors, and in 16 'wish-list' items.These were merged into a total of 68 categories: 29 helping, 30 hindering and 9 'wish-list' categories.Of the helping categories, 26 reached a participation rate of at least 25%, as did 28 of the hindering categories.Of the 'wish-list' categories, three were endorsed by >25% of the participants.Based on the helping versus the hindering factors, five contradictory themes emerged: A Clear Picture vs.A Blurred Picture; The Guardian's Competencies vs.The Guardian's Limitations; The Child's/Adolescent's Capability vs.The Child's/Adolescent's Incapability; The Nurse's Skills vs.The Nurse's Challenges: and The Context of the Call Facilitates vs.The Context of the Call Complicates.
The nurses described their work with assessments and telephone triage as a stimulating, meaningful and challenging task, requiring experience, nursing skills and peer support.A typical call, resulting in triage to the CAMHS, lasted about 45 min.Many of the nurses emphasised that good quality nursing and professional counselling to worried guardians were a priority, and that the variety of the calls was both challenging and invigorating.To assess the child's or adolescent's well-being and possible mental health problems, based on the guardian's statements, was described as a task requiring special nursing skills.The absence of the physical meeting demanded the skill of listening carefully to what was said, as well as the manner in which it was conveyed, and perceiving the unspoken messages.
It's very intriguing to perform an assessment based on your ears and brain alone, to learn how to almost hear body language and interplay.To hear the unspoken, to read between the lines, is of great importance here.Perhaps more so than that which is said.
Learning to do this, as well as having the skills to assess and triage to the correct level of care, was described as an experience-based process that developed over time.Many assessments included speaking to both the guardian and the adolescent, which the nurses felt provided a more solid basis for their assessments.It was even described as desirable, particularly in calls concerning adolescents, as guardians often lacked insight regarding their day-to-day life.Adolescents also increasingly contacted the OWI unit, with or without their guardian's knowledge.In these cases, the nurses always performed telephone triage with the adolescent, requesting consent before contacting the guardian.This procedure was described as important in order to maintain a high degree of confidence among the young population, and to strengthen their involvement in their own care.The nurses also described a steady increase in the number of calls per day.When asked to estimate the number of calls answered, one of the nurses believed that about half of them were answered, even though 15-16 nurses were operational at the OWI unit.Hence, a certain amount of stress was present.All the nurses perceived their work as meaningful and of great societal importance, as the counselling provided ultimately benefitted the children, regardless of whether triage to the CAMHS was indicated or not.This created a sense of professional satisfaction.

Helping and hindering factors in telephone triage
Each of the five contradictory themes contains categories with varied participation rates.Only the highest rating categories will be described in depth.Citations are used to clarify the contents, in order to ensure the confidentiality of the participants, the citations are not specified.Efforts have been made to include the most colourful examples from various participants.The categories of helping and hindering factors are presented in Tables 1 and 2.

A clear picture vs. a blurred picture
The categories in this theme consist of the helping and hindering factors that the nurses singled out as being the most important when assessing psychiatric disorders in children.Distinct symptoms and reductions in day-to-day functioning were seen as helping factors by all the nurses.This, in combination with accelerating or recurring symptoms, was supported by the results of the BCFPI, providing a solid base for triage to the CAMHS.
The mother tells me that he doesn't leave home, stays up all night, sleeps a little during the days, rarely eats, has spoken about a desire to die, that he is afraid of hurting himself -all alarm bells are ringing.
In contrast, factors described as hindering for the assessments were when symptoms presented were vague and the support of the BCFPI was weak or did not correspond to the facts conveyed by the guardian.The category Context of the child contains things that complicated the assessments, mainly related to the child's social environment.This could, for example, be connected to severe cooperation difficulties due to separations, or to complex situations including the whole family and contact with the social services.Such circumstances made it difficult for the nurses to extract the actual symptoms and problems of the child and thus affected the triage.
This seems to be a task for the social services, because the siblings are fighting.They seem insecure and blaming their mother because …//… I mean, this isn't something for the CAMHS, it must be solved within the family.But at the same time, it's hard to know what's what.
The nurses also described cases in which separated guardians had different views regarding the problems of the child or adolescent.Sometimes one of the guardians opposed contact with the CAMHS, which complicated the process.In cases with complex family-related problems, the nurses also, at times, filed a report to the social services.

The guardian's competencies vs. the guardian's limitations
It was of great importance to the nurses that the person providing them with information had the capacity to convey the symptoms and functioning of the child.Thus, the guardian's communication skills played a significant role during the assessment.That the guardian gave a stable impression and described the problems at hand, sometimes with the support of the nurse, was essential.The guardian's knowledge of the child's perception of his or her situation, and the guardian's statements being supported by the BCFPI, also simplified the assessment.
He described the course of events, gave very specific information about symptoms.He had spoken to his boy about the problems and had asked him how he felt about things.
Language barriers were described as a hindering factor by all the nurses.In calls where guardians had difficulties expressing themselves in Swedish, or understanding the nurse, the basis for the assessment was limited.It was not possible to perform telephone triage with a language interpreter.Lacking information, and support of the BCFPI, as the BCFPI is only utilised in Swedish, these children were often triaged to the primary CAMHS care level.At the CAMHS clinic, the assessment was made in person, using an interpreter, which the nurses felt was more appropriate and increased patient safety.Other factors hindering the assessment were guardians' inability to describe the child's problems, and guardians who seemed unbalanced.Distraught guardians were also described as problematic, as their descriptions of the child were often tainted by their emotions.To facilitate the assessment the nurses had different ways of calming the situation and helping the guardians compose themselves.One nurse explained how she used to handle this kind of situation: Sometimes, I'll say, 'I can hear that you're really upset right now, why don't we take a break?Use the toilet, have a cup of coffee, and I'll call you back in fifteen minutes?'

The child's/adolescent's capability vs. the child's/ adolescent's incapability
Speaking directly with the child was something that all the nurses endorsed, especially when the child was older or adolescent.To ask the child questions regarding depression or suicidal thoughts was sometimes daunting to the guardian, whereas the nurses perceived that the children were often very honest and capable when speaking with them.

Sometimes when I speak to an adolescent who, for example is self-harming, when I ask if he or she has told his or her guardians about it they say -'Oh no, I can´t!' But when I offer to tell their guardian and explain why this is important, they often let me do it.
The child's capability to communicate also played an important role, even though the nurses sometimes modified their manner of asking questions and speaking, compared to the assessments with guardians.

When you are speaking to a verbally capable child who can express what he or she is feeling and thinking -that does affect the triage.
Hindering factors involving the child were mainly described as occurring if the child opposed contact with the CAMHS, even though the assessment indicated a need.Sometimes the opposition derived from the fact that the child was incapable of understanding or sharing the guardian's view of the problem, and at other times a previous bad experience with the CAMHS or social services, affected their attitude.
…//… the mother described a really tough situation, but when I spoke with the boy he denied everything, he did not have any problems and did not want help.
This did not always impair the nurses' ability to perform the assessment, but many of them clearly stated that the child's involvement was necessary and that he or she at least had to accept a first visit to the CAMHS clinic.The nurses offered advice and support in these cases, to help the guardian motivate the child.In contrast, if adolescents made contact without the guardian's knowledge, the adolescent's consent to inform the guardian was desirable.This was described as sometimes problematic in cases where the adolescent refused, since the CAMHS clinic prefer the guardian's presence at the visit.Contact with the guardian also provided valuable background information complementing the assessment.Mostly, though, the adolescents did consent, as the nurses explained the importance of the guardian's involvement.

The nurse's skills vs. the nurse's challenges
The helping factors in this theme captured the nurses' own sense of certainty during their assessments.The ability to trust in one's assessment and decision was clearly related to experience, as was the skill of determining whether to triage The importance of peer support was also highly endorsed.Almost all the nurses mentioned the possibility to discuss cases with colleagues as a way of gaining more experience and assertiveness.Alliance with the guardian was deemed helpful and important for the assessment and the nurses strived to achieve an empathic, non-judgemental attitude.
Disagreement with the guardian, however, was described as hindering, especially concerning the assessment of the child's problems.Many of the nurses had experiences of challenging assessments when guardian and nurses perceived the problems differently.For example, when the guardian wished for desired contact with the CAMHS regarding potential neurodevelopmental disorders, and the nurse considered the problems described more likely to relate to other factors, such as teenage behaviour.In other cases, the opposite could occur.
This mother just wanted her child to receive contact with a therapist even though it was clear to me that the child needed a neurodevelopmental assessment.It was very challenging to try to explain why I wanted them to receive a contact with a broader focus.
These situations were often resolved, but sometimes the nurse felt compelled to triage to the CAMHS to maintain alliance.
The category Ethical dilemmas in triage refers to factors entailing, for example, triage of older adolescents to the CAMHS, whilst knowing that it was unlikely that the adolescents would receive treatment before they turned eighteen and that they would be transferred to the adult psychiatric services instead.Another ethical dilemma described, entailed recurring cases where a previous contact with CAMHS had been ended and the guardian called again.
They had been to the CAMHS clinic previously, and the assessment did not amount to any follow-up or treatment.Even though the problems persist I suspect that the result will be the same, if I triage them to CAMHS again, which feels frustrating.

The context of the call facilitates vs. the context of the call complicates
This theme contains categories such as Direct questions and structure, capturing the process of telephone triage using the screening questions and the BCFPI, which helped both the nurse and the guardian keep focus and cover all important issues.
Many guardians are worried that they might forget to tell me something important but feel reassured when I tell them that we will cover everything using the screening questions.
To perform the assessment with one guardian, as opposed to both guardians, was described as ideal regarding the structure.Moreover, the possibility to take a pause to reflect was valuable when in doubt where to triage.
It is somehow easier during a phone call, than in a face to face meeting, to say -'Listen, I need a moment to consider, is it okay if I call you back in a few minutes?' External disturbances were described as major hindering factors that affected the assessment.Examples of this were noise and interruptions from younger children, or poor mobile reception if the calls came from cars or were made outdoors, resulting in a lack of concentration on the part of both parties.Many nurses also described lack of time as a frequently hindering factor, causing frustration.That the structured assessment was time consuming was not always appreciated by the guardians, especially if they had perceived that they called the OWI unit to simply schedule an appointment within the CAMHS.
When she realized that this assessment that probably might take 45 minutes, she was very upset because she had not anticipated that.
The fact that the BCFPI was not eligible for adolescents, or for guardians having language difficulties, this affected the triage since the basis for assessments was less substantial.Digital self-referrals from adolescents were generally perceived as positive by the nurses.The negative aspect described was that guardians are not allowed to make digital self-referrals concerning adolescents, which the nurses considered a restriction in accessibility.This could also cause situations like the one described by one nurse:

'Wish-list' items
The things nurses thought might improve the assessments and the triage process were generally more diverse than other factors.Self-screening for adolescents corresponding to the BCFPI for guardians, was considered desirable.
Improved information to guardians to better prepare them for the OWI assessment was also suggested.The CAMHS units had different routines regarding how to manage bookings and guidelines for triage, which caused frustration and a sense of lack of control.Therefore, some of the nurses desired a common structure for all the CAMHS units.
When I am unable to provide them with an appointment directly over the phone, I must rely on the CAMHS clinic to make the appointment it which makes me feel uneasy, especially if the child is in urgent need for care.
The Table 3 presents the categories of the 'wish-list' items.

Discussion
The results of this study illuminate the complexity of telephone triage within a CAMHS setting and provide procedural insight, capturing that the communication between the nurse and the guardian or the child, constitutes the essential basis of the assessment.Guardians with difficulties describing the situation at hand, due to language problems or for other reasons, are a challenge for the nurses, and prompt them to use a range of skills to obtain information.The interaction between nurse and guardian mostly results in alliance and a shared view.This is in accordance with the theory of interpersonal relations, which emphasises that the nurse's response to the patients' needs, and experiences is essential in supporting the patients and understanding what is meaningful to them (D' Antonio et al., 2014).The way the nurses in this study described their conversations with guardians, children, or adolescents, offering a sounding board to their concerns and needs, very much illuminates the essence of child and adolescent mental health nursing.
The nurses conveyed that the use of the BCFPI contributes to the comprehension of the situation, but that their own clinical assessment, based on experience and competence, plays a pivotal role.The nurses also described how the guardian's emotions or convictions sometimes affect triage, resulting in contact with the CAMHS even if the assessment does not fully support it.Similar aspects have been observed in a meta-ethnographic study regarding telephone triage in different healthcare contexts (Purc-Stephenson & Thrasher, 2010), highlighting the challenging task of performing a clinical assessment via telephone.
That an increasing number of adolescents initiate contact, with or without their guardian's knowledge, was surprising to the authors.The finding that the nurses welcome this, sheds light on the importance of first-hand information to make exhaustive assessments.It also underlines an urgent need of developing screening tools aimed at adolescents, since the BCFPI is used exclusively with guardians at the OWI unit.Kazdin (2019) concludes that many children/adolescents do not seek help within mental health services to an extent corresponding to their needs, and argues that new ways of encouraging them to do so are required.Perhaps the OWI units' model, offering digital self-referral, is a step in this direction, more suited for the young of today than traditional ways, such as calling or visiting the CAMHS.Overall, the nurses conveyed a strong sense of respect for children as active participants in the care process, striving to empower them.This is aligned with current Swedish law (SFS 2018(SFS :1197(SFS , 2018)), which emphasises that every child is entitled to information and participation in their own healthcare.Sahlberg et al. (2020) point out that children who need healthcare are an especially vulnerable group and that high standards are required of healthcare personnel regarding compliance with the law.
Prior research indicates that assessing and prioritising the need of care in mental health telephone triage requires competence and skills.Sands et al. (2012aSands et al. ( , 2012b) ) concluded that clinicians use a wide variety of practical strategies, psychosocial interventions and therapeutic skills.By utilising an observational design, they identified several core areas of clinical competence, such as being able to initiate and terminate calls, perform mental status examinations and offer brief interventions, along with risk assessment, time management skills and skills to manage challenging callers (ibid.).These special skills are not directly transferable to the skills required in face-to face consultations and therefore special training is needed to perform telephone triage (Purc-Stephenson & Thrasher 2010).The competence and skills required of the nurses were not the focus of the present study, however.Instead, the ECIT method was utilised to capture the perceptions of the nurses themselves, rather than creating an objective description of the activity.Even so, the findings of Sands et al. (2012aSands et al. ( , 2012b) ) seem to resonate in the OWI setting, and their studies and the present one may complement each other in describing different aspects of mental health telephone triage.
The results of this study illuminate helping or hindering factors in telephone triage in a CAMHS setting.The study provides insight into what steps could be taken to improve the quality of care given and into ways to advance, for example, the information available to the public, specifically information concerning the assessment and triage that the nurses perform.The importance of being well prepared, and of understanding that a call to the OWI unit entails a qualified CAMHS assessment, needs to be more distinctly conveyed to the guardians.Furthermore, making sure that the BCFPI is available in other languages, combined with the use of interpreters, seems pertinent and should be considered, since language barriers pose a significant challenge.Another aspect is the need to implement a modified version of the BCFPI, or alternative structured assessment tools, aimed at adolescents.
The nurses described their actions within the OWI unit as having great importance to those in need of professional guidance regarding the mental well-being of their children.To offer easily accessible mental health counselling to guardians and adolescents on this broad scale, might prove beneficial for society and the general well-being of children and adolescents, ultimately reducing the expected need of the CAMHS.The concept of telephone triage has been shown to be efficient within other areas, for example, within emergency medical services, reducing the need for non-urgent emergency medical services by one third (Roivainen et al., 2020).As the need to improve children's mental health is a matter of international interest (Kazdin, 2019;Kieling et al., 2011), and as we might be facing an increase of mental illness in the aftermath of the COVID-19 pandemic (Racine et al., 2021), other CAMHS could find it helpful to review the process of telephone triage.

Limitations and strengths
The choice of ECIT for this study was primarily based on the specific aim to illuminate nurses' perceptions of telephone triage in a CAMHS setting, regarding factors that facilitate or complicate the assessments and triage.In addition, following an extensive guide by Butterfield et al. (2009), concerning both the collection of materials and how to analyse them, enabled the study.Since this methodology is relatively new in Sweden, some methodological issues occurred; for example, there are no ECIT experts available for reviewing the process.However, efforts have been made to follow Butterfield et al. 's directives as closely as possible.
The specific aim of ECIT, i.e. to examine an activity in detail based on the perceptions of the individuals involved, gave a depth and richness to the findings that would likely not have been achieved with any other method.A trustworthy ECIT result should consist of a minimum of 100 CIs (Butterfield et al., 2009).This study resulted in 305 CIs/ factors, thus exceeding the minimum by far.That the result reached a high degree of exhaustiveness and variability implicates that most factors were covered.Therefore, it is probable that the result is transferable to other OWI units, and possibly to similar practices in general.It is possible that even more factors would have emerged with a larger number of participants.However, the long work experience and broad competence provides a high variance of the study sample.
The present study, is to our knowledge, the first to illuminate several aspects of telephone triage in a CAMHS setting, but more research is needed to comprehensively understand the practice, its usefulness and cost effectiveness.The special nursing skills required to perform the complex task of conducting triage via telephone, based on second-hand information from guardians, also needs further investigation.Deeper knowledge of the OWI units' impact on the community, with regard to accessibility to healthcare and the consulting quality of their services, should also be of interest, possibly inspiring other CAMHS to launch their own OWI units.

Table 1 .
Helping factors -themes and categories.
BCFPI: Brief Child and Family Phone Interview form; CaMHs: Child and adolescent Mental Health services.

Table 2 .
Hindering factors -themes and categories.Brief Child and Family Phone Interview form; CaMHs: Child and adolescent Mental Health services.to the CAMHS or not.Two of the nurses described it like this: I based my decision … on more of a feeling … that the conversation with the guardian gave me.-Experience, ah, I can't really say what it was, but I triaged the errand to the specialised CAMHS.