|It's Your Call: The World of
Nanette Lavoie-Vaughan, ARNP-C, MSN
Sandy Keefe, RN, MSN
telephonic nursing, RNs use their best assessment skills
to make reasonable deductions.
On a cold winter morning in Broomfield, CO, Cindy Wendling, RN, BSN, walks into the McKesson Health Solutions Care Center. Heading to her workstation, she boots up her computer and takes a few moments to ergonomically arrange the computer keyboard, mouse pad, telephone headset, and resource materials. For the next few hours, Wendling fields a steady stream of inbound calls from patients seeking advice from her, the telephone triage nurse.
She fields calls from mothers about children with rash, cough, or vomiting; queries that warrant further investigation by a healthcare practitioner; and every now and then, a true emergency: crushing chest pain or neurological changes that suggest stroke. Wendling handles the calls with ease, referring to a sophisticated set of algorithm-based protocols on the computer that guide her to an endpoint. As part of the call, she may provide approved home care advice, recommend a call to the primary care physician, or even urge the caller to contact 911. After a moment or two to wrap up the details on the computer, Wendling is on to the next caller.
Later that evening, Barbara Mallari, RN, BSN, logs on to the computer system at Health Net Federal Services in Rancho Cordova, CA. As a healthcare finder on the after-hours line, she answers calls forwarded from military bases across 11 states. Mallari can authorize treatment at base hospitals or clinics; when no military treatment facilities are nearby, she uses the Internet to locate nearby civilian resources. Many of Mallaris calls are from members of the armed forces who are traveling away from their home base. She also spends a good deal of time talking with military wives, many who are the sole caregivers for their children because their spouses have been deployed. Like Wendling, Mallari has calls that range from the mundane to the emergent. Although she doesnt officially triage the situation, You do need to have a sense of whats a 911 or ER call and act accordingly, she says.
Mona Mathewson, RN, MSN, provides quality assurance and education to clinical nurse consultants at a LifeMasters® Supported SelfCares call center, which is located in a suburb of Sacramento. The consultants, who provide telephonic disease management services, have a set list of appointments each day similar to clinic appointments. Throughout the day, nurses scheduled outbound calls to program participants with congestive heart failure, diabetes, coronary artery disease, hypertension, chronic obstructive pulmonary disease, and asthma. Although the calls focus heavily on health teaching, program participants are also encouraged to monitor and report vital signs for review by the nurse consultants. Changes can be picked up early, often averting ED visits or hospitalization.
What About Patient Contact?
The callers are so sweet and respectful of nurses, says Mallari. Its important to listen to the message behind their words. I like working here our goal is actually to delight the caller. Not just to do a good job, but to delight them with our interest, responsiveness, and level of service.
You have to listen to what theyre saying with their emotions as well as their words, Wendling echoes. Many times, Ill say something like I hear you or I see what youre saying. Then there will be a moment of silence, and the person Im talking with will get all choked up or give a big sigh. When asked if she missed direct patient contact, Wendling seemed surprised. You know, I develop a good, warm rapport in the short time Im on the phone. I joke and commiserate. I get that kind of empathetic communication that means so much to me as a nurse.
Rather than taking away the nurses autonomy, the software programs used in telephonic nursing actually enhance the nurses ability to make good decisions, says Wendling. The information is all there, but you can override the endpoints by using good nursing judgment and providing sound rationale. The computer never makes the final decision thats why RNs are so necessary in this environment. We have to use our best assessment skills and make reasonable deductions. Telephonic nursing is not a field for someone who needs to be constantly guided, she says.
When asked about the less enjoyable aspects of their jobs, both Mallari and Wendling mentioned lack of follow-up with the patient. In the hospital, Wendling says, you could always check the next day to see how things went with your patients. Here, we do some call backs to check on outcomes, but thats limited. Mathewson, however, makes regular calls to participants and enjoys follow-up as one of the benefits of disease management nursing.
As usual, weekends, holidays, and shift times can be issues. Wendling works every other weekend and is obligated to every other holiday. Mallari chooses to work every weekend to be home with her children more during the week. She selected an evening shift to accommodate her family schedule. Wendling, on the other hand, has the day shift of her choosing. Disease management nurses, Mathewson explains, work primarily during day and early evening hours, with lighter coverage on weekends and holidays.
Bringing the Right Skills to the Job
All three nurses describe nursing assessment and patient teaching as the bedrock of telephonic nursing. You have to bring a true passion for health education to this position, Mathewson says. You need to evaluate how ready the person is and what he needs to change behaviors. Then you make a real impact on quality of life.
You absolutely use more nursing skills to communicate on the phone without the nonverbal input, Mallari concurs. Wendling cites a solid grasp of normal anatomy and physiology, as well as pathophysiology of common disease states, as key requisites for telephone nurses. You need to be comfortable thinking on your feet and making decisions, she says.
While telephonic nursing doesnt require high-speed typing, most call centers look for nurses with basic keyboarding skills, familiarity with use of the mouse, and comfort with e-mail. Most call centers have productivity goals and regularly audit nurses calls. You know, its no big deal, says Wendling. The software is quick, the supervisors are reasonable, and you get comfortable with the flow and the productivity requirements. For disease management nurses, Mathewson says, While there are appointment times to keep, the time is sufficient to give participants what they need.
Nurses also need to be comfortable with the idea that others can hear what theyre saying the nurses in surrounding work stations, or supervisors listening to calls. If youre a nurse who never wants feedback, this isnt the place for you, says Wendling.
Exploring Telephonic Nursing
Nurses who want to find out more about telephonic nursing may want to take a home study course. Another option is to contact local companies who operate call centers, and ask for an opportunity to come in for a tour and a chance to talk with the nurses.
Sandy Keefe, RN, MSN, writes frequently for Nursing Spectrum.