Thursday, September 28, 2017

The Interview Process

With telephone triage, the caller has no idea what the nurse is doing or if they are even listening, and it is imperative that the interview process be successful. It completely determines the outcome of the call. There are some things the nurse can do to enhance the quality of the interview and guide the call to a successful outcome.
First, explain long silences to the caller. You can state "Thank you for the information. I am just getting it all documented", or "Give me a minute to think to make sure we are not overlooking anything". Callers will appreciate knowing that are you listening and not doing something else.
The caller should receive the upmost attention, but if you have to place them on hold for any reason, explain why and thank them for holding. If you have to keep them on hold for more than 2-3 minutes, you should come back them and  explain why the extended hold, and apologize.
Don't chew gum or eat while on the phone. That is self explanatory and is unprofessional.
Call the patient by name. Most people prefer to be called by their first name, but we should never make that assumption. It is professional to ask patients if you have their permission to address them in that manner.
Be real to the caller. Give each caller the personal touch. Speak to each one warmly rather than in an automated tone.
Finally, the most important thing to remember is put yourself in the caller's shoes. We as nurses, have an understanding of how the body works and about health conditions. If we are sick, we understand the symptoms and what is happening. However, equate this to someone who does not even understand what the term fracture means. Listen to the caller, be patient, and try to remember what it was like before you became a nurse.
Studies comparing providers who have been sued comparing to those that have never been sued showed that those that were never sued spent just a couple of extra minutes with the patient, showed concern, were accessible, were good listeners who invited questions, got the exam out of the way first, asked open ended questions, used humor, involved the family, explained and checked for understanding, negotiated, expressed interest, and encouraged conversation. These are all qualities that would serve telephone triage nurses well.

Wednesday, August 2, 2017

Recipe for a Successful Call

If you have been a triage nurse for any period of time, you can remember at least one call that you just felt like was not successful. It could be that the caller was frustrated with previous encounters with medical personnel, too anxious to really listen to your advice, or maybe you felt like you were not prepared enough. Yes, there is always at least one that sticks out in your mind.
How do you prevent that from happening again? There are some steps to follow to ensure both you and the caller are pleased with the outcome.
1. Be familiar with your facility or company's adapted protocols or algorithms. Know where and how to access the correct protocol quickly and efficiently. If you cannot do so, the caller will know you are not prepared and will have decreased confidence in your abilities and be less likely to follow any advice you give.
2. Be able to draw on your own knowledge and past experiences. There are appropriate times to interject additional education and information to assist the caller with getting to the next level of care.
3. Develop a relationship with the caller. This is probably the most important thing you can do to ensure a positive outcome. Callers are seeking medical advice, but they also want to know they are being heard. It is important to really listen to what they are saying and be empathetic, even if it means you have to stop typing for a moment to give them your undivided attention. We often get so focused on gathering information that we may not realize that callers pay attention to what they hear as well. I had a caller say to me once, "Can you please just stop typing for a minute and listen to me?" I was listening to her, but because she heard the sound of my fingers hitting the keys, she felt she did not have my undivided attention. They do not care how much you know until they know how much you care.
4. Educate the caller. Don't just be the person who hands out advice. Explain why you are recommending the disposition. Explain risks of not complying. Instruct them on red flags to watch for and when to call back.
5. Finally, ensure them they are not alone. Let them know that help is just a call away, and they can call back at any time if they have further concerns or questions.
There is nothing like the feeling of success when you disconnect from the caller knowing they are appreciative of the conversation you just had, and knowing you were able to help in their time of need.

Tuesday, June 13, 2017

The Triage Nurse's Role as a Detective

A skilled triage nurse knows that every call he/she receives should never be taken for face value. So many times the initial complaint may be one symptom and turn out to be something completely different, and potentially serious.
Here is a good example of this. The initial message from the answering service came in as infected bug bite. The nurse, being as diligent as she was, pulled up the insect bite protocol, and returned the mother's call. The mother stated the child had an insect bite for a couple of days and was showing symptoms of infection. The child was complaining that morning of not feeling well. The mother is a diabetic, but the child had never had any diagnosis so the mom decided to check the child's blood sugar just to see and it was over 300. Now the call had just taken a 360 degree turn. It had gone from what seemed simple, and could be treated the next day in the office to an immediate emergency room referral.
This situation would be a good example of the skill and expertise that is needed to be a triage nurse, and why unlicensed personnel should not be in this role. It also requires a variety of experience to be able to recognize that the biggest problem was not the insect bite, but the child could potentially be an undiagnosed Type I diabetic. It also then takes knowledge to know where to locate the correct protocol and chose the correct plan and disposition.
An experienced triage nurse knows what assessment questions to ask to determine the issue at hand, and has excellent listening skills to be able to determine if a small bit of information elicited from the caller could be something that needs to be investigated further. They interview, investigate, listen to the caller, listen for background noises that could potentially help, such as the quality of the cough from the child that the parent could be calling about, and then, they are able to take all that information and determine a plan that is the safest and most effective for the patient.
Being a skilled triage nurse means being a skilled detective.

Friday, April 21, 2017

Recipe for a Successful Mentor/Mentee Relationship

Not everyone can be a good mentor. Selecting a great mentor involves being able to discern the qualities that person exhibits that would promote a successful mentoring relationship. A great mentor should not be forced into the role. If mentoring is something that person feels they are not comfortable with, then that should be respected. If forced into the role, the mentor will be less productive in their own role, and the mentee's development will suffer in the process. Mentoring is not for everyone.
What are the ingredients for a great mentor? Probably the main ingredient is the mentor is respectful and treats others the way they would like to be treated. They are approachable, accessible, and they never make the learner feel inferior or less intelligent. They listen attentively to any concerns or questions and strive to seek answers and rectify any issues.
A great mentor draws on their own past experiences. They implement their successes and they learn from their failures. They draw on this experience to teach the mentee, and they use examples to aid the mentee learning experience.
The mentor must also remember they can learn from the mentee. Even though the mentee might be less experienced in their current role than the mentor, they still have their own experiences they bring to the table. The mentor should always remember they can still learn from others as well.
There are a few ingredients for a successful mentee experience as well. For the mentee to have a successful learning experience, they also need to be respectful and always say thank you. They should listen with an open mind, and take time to communicate with the mentor. In other words, follow the golden rule.
A successful mentee asks questions, seeks clarification, follows up with help given, and welcomes feedback on their performance (both positive and negative). They are respectful of the mentor's time.
The main thing both the mentor and the mentee must keep in mind is that they are in this relationship to witness a seedling that was planted grow and flourish into a strong, beautiful vine. A well nourished vine continues to grow, and from that, other seedlings can be planted. Thus the product of a successful mentor/mentee relationship could be the mentee one day becomes a mentor too.

Wednesday, February 15, 2017

Validating the Caller

It has been a while since I posted, and I apologize. I took a hiatus, but I am back.
During the hiatus, I learned about something called motivational interviewing. You may have heard about it, and wonder how it can have anything to do with triage. It can work as a great compliment to telephone triage for that matter, and here is how.
I have talked in previous posts about educating to comply. This is a very important part of triage. With motivational interviewing, you empower the caller to make the correct choices, and you make them a very importance part of that choice making without making them feel like they are being belittled or looked down upon. I think we, as triage nurses, are so caught up in getting from one call to another, that we tend to find ourselves repeating the same advice and instructions without considering the level of education of the caller or their knowledge of medication or diagnosis. If we are not careful with our approach, we can leave the caller feeling like they were not heard or we did not really help them with their problem at hand.
The history of MI is marked by a consistent commitment to respecting and caring for the patient. The technique is to learn how to implement this spirit through the use of specific verbal techniques that guide ambivalent or resistant patients to change their current behavior or method for dealing with the problem at hand, and guiding them to seek the correct treatment.
The first step is to establish an interpersonal connection that respects and honors the perspective of the caller. By not shaming or blaming the caller, the triage nurse can create a sense of safety that will allow the caller to be honest and open about the problem they are dealing with.
One important step is to express empathy. If you have a caller that is dealing with a traumatic illness or occurrence in their lives, letting them know by your choice of words, that they have been heard, understood and respected, goes a long way. When the triage nurse empathizes with the caller, they are essentially telling them that how they are making sense of their situation matters to that nurse.
For example, a mother of a 2 yr old with a fever for 3 days calls, and  the child has no other symptoms or history, except that child finished chemo 6 months ago for leukemia. Chances are, the fever is related to a benign virus, but to this mother, it could mean the leukemia is back, and she is panicked. Choosing to say, "It is understandable that you would be so concerned",compared to "I understand why you are so concerned", could make a huge difference in how that mother perceives how much she feels you are really being empathetic and listening to her. Unless you have had a child with leukemia also, you cannot completely relate to what that mother is going through. So, to say, "I understand', compared to saying "That is understandable", can have a great bearing on the rest of the conversation, and the goal should be to assess the situation, educate on the correct choice for next steps, and any follow up the caller needs to make. If the caller feels they were heard and respected, they are more likely to listen to the triage nurse, follow the advice given, and be pleased with the outcome of the call.

Wednesday, October 14, 2015

Educating to Comply

Education and triage fit together like icing on a cake. Triage is the cake, but it is just not complete without the education piece on top. Makes the entire call sweeter. It would not be a thorough triage experience without it. Callers need to understand what led the nurse to come to the appropriate disposition, and the more they understand, the more likely they are to comply.
When educating the callers, information needs to be relayed on a level they can comprehend. You have to consider the fact that probably 30% of the callers are college graduates, and even fewer of those have any medical background. So, using medical terms, even as simple as asking if a cough sounds congested, may be more than some callers understand. Instead, asking if the cough sounds wet or dry might be a more appropriate phrase. If the caller then tells you that with that wet cough, the child is speaking in shortened sentences and wheezing constantly, and you instruct them to take the child to the ED, they need to understand the seriousness of the child's condition. It is our duty, as triage nurses, to instill enough fear to get the caller to comply.
Should you tell them that their child will go into respiratory distress and die? Of course not. However, the diligent triage nurse would explain to the parent what is going on with the child that is causing them to wheeze and speak in shortened sentences, and if they wait, the child's symptoms could become much worse before morning. On the other hand, if the nurse just instructs the parent to take the child to the ED, and does not explain why, the parent might decide they do not want to go wait hours in the ED and decide to wait it out. This could result in detrimental consequences to the child.
An experienced triage nurse said to me recently that telephone triage is like experiencing emergency room nursing over the phone. The draw back is you cannot see or touch the patient. This could not be more true. This simply means we have to work harder to empower the callers with information to help them to make the best choice for care that is agreeable by all and safe for the patient.

Wednesday, September 2, 2015

It's All About the Detective Work

When I think of the right way to triage, I think about how to be a good detective. Triage is about sorting through the details to get to the root of the problem, and isn't that what detective work is too?

With triage, you should have protocols or algorithms to follow that are symptom based. If you do not have these in place, then you probably do not have a safe triage program. However, so many nurses get so caught up in sticking closely to these guidelines that they do not allow themselves do think outside the box.

Let me give you an example. A mom calls about a child with a low temperature. The child's temp is 97.1R. In the conversation, the mom tells the nurse that the child was outside earlier in the day, in freezing temps, without proper winter clothing. After which, she came in, bathed and then started to appear as if she was really not feeling well. At that point, the mom decided to take her temperature. The child is now in bed, very fatigued, and barely responsive to mom. The nurse, hearing this, automatically starts thinking frostbite, and goes straight to that protocol. She shuts down the possibility of any other symptoms and fails to ask. She gives mom homecare advice to warm the child, and told mom to call back if symptoms do not improve. The mom follows the nurse's advice, and by morning, the child was rushed to the ED with symptoms of sepsis. If the nurse had opened her mind to other possibilities and asked if the child was recently treated for any illness or injury, or asked if she had any other symptoms present; she would have discovered that the child had just finished a course of antibiotics for a wound infection. The wound was not appearing better, and the mom intended to call the physician's office the next morning to report it.

We can never assume callers are telling us the whole story. It is our duty to ask for it. Many times, the caller assumes that certain information is not relevant and do not think that we need to know. Solving the mystery means asking for the details, sorting through them, following the appropriate guidelines, and coming up with a solution that is safe, agreeable by all, and is in the best interest of the patient.