"Your ears become your eyes": managing the absence of visibility in NHS Direct.
To identify and describe nurses' perceptions of interactional practices they use to manage the absence of visual cues in telephone consultations with callers at an NHS Direct site. A routine activity in telephone consultations is visualizing the patient and the situation from which the call is made, that is, "building a picture of the patient". Little is known about interactional practices between nurse and caller that contribute to shaping a conception of the caller, or other activities that nurses do to manage the absence of visibility in the consultation. Qualitative analysis of semi-structured interviews conducted with nurses new to NHS Direct telephone consultations, the first immediately prior to the NHS Direct site's opening, and the second 6 months later. The activity of visualizing patients and their environment is closely linked to interactional practices carried out between nurse and caller. Nurses described a range of interactional activities that they perceive help callers to describe with more precision what the nurse cannot see. Nurses also tailor interaction to a nonvisual environment in order to manage the more emotional aspects of telephone consultations, such as delivering information, advice, reassurance, and building trust and rapport. Nurses developed skills to manage interaction with callers in order to compensate for the absence of visibility. Skills were based on their professional backgrounds and experience and developed in an ad hoc way. Further research could examine the efficacy of these strategies, and be a prerequisite to adding them to training programmes.