Thursday, December 28, 2017

Why I am a Telephone Triage Nurse



As I was speaking with a friend and co-worker the other day, we talked about why we liked our job, and how we reap the benefits in our personal lives. We both agreed we would not have it any other way. That conversation has resonated with me since then, and I have been thinking about why we do what we do every day.
Thinking back to that conversation, on this cold December evening, I started remembering all the different nursing positions I have held in my career, and about the times I have had to have to go out at all hours to visit patients during my tenure as a home health/hospice nurse. I remember driving on back roads that were icy and snowy to make those visits, and even times, I parked my car, grabbed my bag, and walked in to see patients because it was just not safe to drive. I also remember, during snow storms, packing a change of clothes, telling my family I was not sure when I would be home, and catching a ride to the hospital to work my shift. All because that is what you do when you are a nurse.
Reminiscing about prior positions, different patients over the years have come to mind as well. There were patients that I can still remember their names, and there are some that their name is not so clear, but the bonds we developed, I will always cherish. There are also patients that I would rather forget because they were difficult, and well, let’s face, just mean.
Being a nurse does not come without injury at times either. You risk being bitten, hit, kicked, and God-forbid seriously injured by a patient who has serious mental issues. There are also risks of physical injury from the strain of lifting, bending and pushing objects that weigh more than they should.
When I discovered telephone triage nursing, I never knew such a position existed.  At that time, I was searching online for work at home positions for nurses. My mother had recently moved in because her health was declining, and I knew that I soon needed to be available for her more. Working outside the home was not going to be an option any longer.
I secured a position with a very small company as a contracted nurse. At that time, the pay scale was that of a new graduate, but it was not the pay I was seeking. It was the position.  Training was not paid, and I had to travel two hours one way to train with another nurse. The nurse, who was gracious enough to let me into her home, was very good at her job and made it seem so easy. I had no idea what I was getting myself into. I just knew I needed this to continue earning income. I was determined I was going to learn this position, and learn it well.
After my training was complete, my first shift on my own was a four-hour block. Admittedly, I did have illusions about working remotely as a telephone triage nurse and thinking how easy the position sounded. I quickly learned it was just that, an illusion.
I had my protocol books all laid out, and with each call, I was so focused that I do not remember even looking at the time until my shift was almost over. I also distinctly remembering I had one of the most severe headaches I ever had, and being exhausted! That is when I realized that although being a telephone triage nurse is not physically demanding, if performed correctly, it is the most mentally challenging positions you will ever hold.
As time went on, I challenged myself to learn other specialties I knew every little about. I had been an adult nurse most of my career, and now I was dealing with pediatrics and obstetrics as well. I wanted to sound to callers that I was self-assured and knowledgeable. Callers will not trust a triage nurse who does not seem to know the content of what they are speaking of.
At this point, I was enjoying my new found position. I liked the new challenges, and I also started to challenge myself to be more efficient. I admired my nurse manager, and I challenged myself to exceed her hourly completed calls. I am that kind of person who wants to excel in whatever I decide to do.
There was something else I was learning about this position. For the first time, in a long time, as a nurse, I felt appreciated. Not just by my employer, but by the callers. As I went from call to call, thoroughly assessing their complaints, finding the right protocols, and offering advice, I could hear the appreciation in their voices. Many openly expressed that appreciation. I thought I had seen all the areas of nursing there was to offer, but there is something about calling a patient’s home that seems to put you right there in the home with them. Their true emotions are exposed, and they seem to be less reserved like they might be in a facility setting.
Just like my experiences working in a facility setting, I have had some telephone encounters, working as a remote telephone triage nurse that forever changed my life. There are still the occasional difficult callers, but for every one of those, there are two who are appreciative.
Over the years, my position has allowed me to care for my mother until she passed away, home-school my children, be at school parties and functions as they got older and go to my own appointments without having to miss any work time. I have been able to work from the comfort of my own home without having to travel in bad weather, and even on days I have been ill  and would have otherwise had to be absent if working elsewhere.
I have been able to work between two homes and travel while working in this position, and ultimately, it has allowed me to be able to move to my dream home on the lake. It is located in a very rural area where positions are limited, and if not for this position, I would have to have waited until retirement to do so.
Lastly, the icing on the cake is the friendships I have developed. I have heard so many others say working at home is so isolating. It is isolating only if you allow it be. This is a wonderful opportunity to meet some great people from other cities and states that you would otherwise never have the privilege of knowing. We converse during off times at work, support each other, share facebook pictures and messages, have phone conversations, and sometimes even get the privilege of meeting face to face. Many have developed closer bonds than they have with their own friends or family who live locally.   
That is why I am a telephone triage nurse. It is not just a job. It is the opportunity to not only help someone, but possibly change their life. It is the opportunity to have a life that I love, and it is the opportunity to develop life-long friendships with awesome nurses who share the same vision.





Tuesday, December 12, 2017

What Traits Does a Successful Triage Nurse Have?

So many think that telephone triage nursing is an easy job. After all, it is just talking on the phone right? Wrong. It is so much more, and is one of the hardest nursing positions you could ever hold. You have to have the ability to "see" the patient over the phone and safely get them to the next level of care.
So, what does it take to be successful in this specialty?
1. The nurse in this role must be self directed. They must be sure of themselves and realize that although their role is limited, they recognize their importance. Flexibility is important, and they must possess a good work ethic.  This is often a very independent role, and  these qualities are a must.
2. The nurse must be be focused on the short-term goal and achieving short term results. They must possess excellent time management skills, and enjoy bite size pieces of information. They measure their success by reaching measurable outcomes.
3. The nurse must be a strong patient advocate.  They must be empathetic, have the ability to gain the patient trust, and be effective in their delivery.
4. The nurse must possess practical intelligence. Telephone triage is a constantly changing specialty. The effective nurse must enjoy learning and be a quick learner. They should also be able to  relate new information to previous knowledge and apply it when necessary.
In summary, the successful triage nurse must be able to prioritize medical emergency calls, explain lab/test results, draw on prior experiences and knowledge, use decision support tools effectively, and communicate effectively with the patient within the patient's level of understanding.
Is this the role for you? It is not for everyone. However, it can be one of the most rewarding specialties in nursing if you possess these qualities.

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.