The Teaching Role

            Nurses take what is foreign to the patient, put into perspective, and make it understandable and less frightening (Benner, 2001). This sums up ninety percent of my job, as a telephone triage nurse, on any given day. Patients call about various symptoms and illnesses, and are looking for explanation and guidance on what they need to do. Often they are worried, frightened, or just plain lost in the huge medical care system. Many of the calls we get are an acute crisis, but sometimes, they call because they want a nurse to explain to them what the doctor did not.

The socioeconomic class of callers varies. Many are college graduates and understand basic medical terms, and others never finished high school. These callers have to be taught in basic terms that a seventh-grader would comprehend. The nurse has to make a basic assessment of the caller’s understanding in the first minute or two of the call.

In determining a critical situation in my own practice, I cannot think of a particular one, but there are a particular group of callers that I enjoy teaching. Those are parents of young children with croup. These parents call alarmed and worried, because their child is experiencing respiratory difficulties. They don’t understand why. Often, they are walking out the door to the ED when the call is placed. It is a job well done when you can talk them off the ledge, and help them to understand croup is a common childhood illness, and most times, the child does well with simple homecare advice.

Callers/patients need and want to know why you are giving the education that you are (Benner, 2001). They are much more likely to comply with instructions if they understand the rationale behind it. Our role, as a teacher, is to help them understand their situation. That is exactly how I teach croup parents. I help them understand why their child is making this terrible noise, symptoms of severe distress, and treatment they can provide at home to give symptom relief. I then follow-up with them about thirty minutes later to assess for improvement, and give other instructions if need be. The parents are appreciative of the care and education, and it gives them a sense of control over the situation, to know they can manage the situation. They also know that they are not alone, and they can pick up the phone and call for support at any time.

Reference

Benner, P. (2001). From novice to expert: excellence and power in clinical nursing practice (Commemorative Ed.) Upper Saddle River, N.J.: Prentice-Hall, Inc.

Humbling Experiences

            As a supervisor for a telephone triage company, I encourage the members of our team to put themselves in the caller’s perspective. It is so easy to get into a routine of dealing with the same types of calls, shift after shift, and become insensitive to the caller’s needs. However, I am very conscious of that fact that they would not call if there in fact, were not a need. No matter how small the problem may seem to us, as a nurse, it could be a mountain to them.

            Our team of nurses is exceptional in that they often go beyond normal procedures to meet the caller’s needs. The care they demonstrate in treating each caller as an individual is phenomenal, and it shows in so many ways, demonstrating that the smallest effort can change the call’s outcome. One of our nurses shared an experience with us recently that shows this level of compassion:

Humbled...And Forever Changed

It was shortly after 8am when I received a call from a Mom regarding her 5 year old son who had started with Croup that morning, exacerbating his Asthma. I could tell Mom was very well versed in the symptoms of Croup/Asthma as well as the treatment. As our conversation continued, She told me she had been up all night, and that her son was doing well with steamy showers, cool air and Albuterol Nebulizer Treatments. She was exhausted and concerned that her child had needed steroids in past, and she was hoping to get the first morning appointment so they could get some rest. I explained to this Mom that this particular office did not give us appointments to book early, nor did they have walk in hrs. Based on that, I told her the office protocol asked that parents call the office after 830am for appointments. No sooner had I said that did I hear Mom again say "Please Miss Can You Help Me?" Mom went on to further state, “My son and I have been up all night. We are very tired, and my daughter is receiving Hospice Care at our home. If you could set up this appointment, it would be immensely helpful to us all.”

 The tears filled my eyes for this Mom and her family, at which point I did what any other nurse would have done, and telephoned the back line of the office. The office was able to give the mom the first morning appointment, and with her Provider. When I relayed this to her, she was very appreciative. I ended the triage call with this mom, and as the tears streamed down my face, I thought, you just never know the road another is walking on the other end of the telephone line...

It took just a couple of extra minutes of this nurse's time to make a difference to this mother, and the nurse realized her value to the callers that day. Amazing, even though we are not at the bedside of the patient, or even in the same room, we can still make a difference.

It's All About Education

     I find that so many nurses become so dependent on the protocols, that they go through each shift with blinders on. Yes, protocols are a huge part of what we do every day, but the one thing that will reassure the caller and prevent multiple call backs in a shift is education.
     We have a duty to educate the caller as to why we are giving the advice that we are. Most people are much more likely to follow the advice they are given if they are given an explanation as to why. And, if a nurse sounds reassuring that he or she is confident in the advice they are giving, the caller is much more likely to take them at face value. If the nurse sound like they are reading from a script or unable to give explanations, the caller is going to be unsettled and more likely to call again or ask to speak with the physician.
     The best way to become a good educator? Know your protocols first. You cannot give reassuring advice if you have no idea what the protocol says. Take some time to familiarize yourself with them. Keep yourself educated and informed on the latest trends and treatments for various illnesses. Follow the CDC as they track new diseases and patterns of illness. Read the updates in periodicals and magazines. Familiarize yourself with new medications that hit the market.
     One great way to keep abreast of the latest trends in telephone triage is to be a member of AAACN. Read their monthly newsletters. Most every month, there is a something for the telephone triage nurse.
     To be an effective telephone triage nurse you cannot be stagnate. It is a constantly changing field, and the callers expect the nurses to be informed and provide them with the answers they need. There is also nothing wrong with saying you don't know the answer, but you will certainly do everything you can to help them find the answers.  Then, make every effort to do so. They will appreciate your honesty and sincere desire to help them in their time of need.

Normal Newborn Concerns

I love talking to first time parents. Many of my colleagues don't, but there is just something about being able to educate them that their little bundle of joy is normal, and what they are experiencing will pass. It is gratifying to hear the relief in their voices when you reassure them that they will survive their sleepless night, and this screaming mess will grow to be a cooing miracle.
Here is a short list of some of the more common things that I find that new parents call about frequently that you may find helpful:

Diarrhea- Breast fed infants bowel movements constantly change, and it is very normal for a breast fed infant to have as many as 10 watery, yellow seedy stools per day. Parents should only be concerned if the infant acts sick, develops a fever, poor sucking reflex, not latching on as well, stools become mucusy or bloody, not urinating, or stools dramatically increase in frequency or any other concerning symptoms. Frequent, liquid stools in a breast fed infant is not necessarily diarrhea.
Cyanosis or mottling of extremities- New parents frequently call about noticing this in the feet especially. The circulatory system of newborns and young babies are not fully developed yet, and the feet appearing blue is very normal. If they feel warm to touch and the infant is exhibiting otherwise normal behavior, you might suggest they elevate the extremities for a brief period and see if the color returns to normal. If not, call back or if any other symptoms seen.
Cyanosis around the mouth-This is know as circum-oral cyanosis or peri-oral cyanosis, and if the lips and tongue are pink, respirations are normal, and infant is feeding well, this is can be normal. The parents will often report it as the infant appears "blue around the mouth". This is due to the engorgement of the venous plexis and is normal.
Irregular Breathing- Newborns often do not have quiet breathing. Especially on falling asleep, newborns can appear to be panting with very rapid breaths. This can last from seconds to minutes. They can also have very long pauses lasting 10 to 15 seconds. This is called periodic breathing and can be alarming, but parents need to be educated this can be perfectly normal as long as it does not persists and the infant has no color change.This is due to the central nervous system not being fully developed yet.

Congestion- Sneezing and congestion can be normal. Newborns have never encountered foreign substances and airflow through their nose, and sneezing is normal process to try to clear the nasal passages. 

Jerking or Twitching- The nervous system is very immature, and newborns are very jittery. Arms, legs, lips and chin can quiver, jerk and shake. They also have an exaggerated startle reflex that can cause them to jerk their arms and/or rhythmically shake their arms. Jitters can be distinguished from seizure activity by holding the arms or legs that are jittery or shaking. Seizures will not stop, but jitters will once the effected body part is held.

I hope these tips may help some of you dealing with nervous new parents. As I said, it is a job well done when you can talk them off the fence, and they can realize they are have a normal healthy infant that they need to nurture and enjoy and not have to worry that something is terribly wrong.

Err on the Side of Caution

I mentioned in a previous post about as RNs, we should exercise critical, independent thinking skills and use protocols as a guidance in helping us do that. The following is an example of how one of our nurse's did just that.
The nurse received the call on a weekend morning from a worried mother regarding her 14 year old son who had been experiencing right sided lower abdominal pain for 24 hours. The only other symptom the child had was abdominal pain on urination. The mom called because the pain appeared to be getting worse, and the child did not sleep well the night before. He had been drinking fluids well, but a had a decreased appetite. He had no other symptoms classic of appendicitis. There was no fever, no vomiting, no pain on palpation, nothing.
One might interpret the symptoms as possible a kidney or bladder stone or maybe even a UTI since there was pain on urination. However, the nurse used the protocol as a guide, and erring on the side of caution, sent the child to the ED for evaluation as the protocol recommended. The child was subsequently diagnosed with acute appendicitis and had an appendectomy later that afternoon.
Often, I find nurses wanting to read too much into the problem and try to second guess or diagnose what they think the problem is. That is not within our scope of practice to diagnose. Our position as effective triage nurses is to recognize there is a potential problem and to determine what needs to be done to get the patient safely to the next level of care, doing so with caution and being intuitive that there could be a potentially worse situation than what we even realize.
Does this mean send all patients to the ED? Of course not. It means using good listening skills, being an excellent critical thinker, and "going with your gut". Just because all the symptoms are not present to give a disposition of ED does not mean that is the best decision to make. If your instinct is telling you that the patient needs a higher level of care, it is best to seek that option for them, and what is the worst that could happen? The patient is seen unnecessarily in the ED. That sure beats the alternative of hearing later that the they suffered undo harm because the nurse did not pick up on the subtle symptoms. Remember, all patients are individuals and do not always present with textbook signs.

Recommended Reading!

I commented on my last post that I am reading the new book written by Carol Rutenberg and Liz Greenberg, The Art and Science of Telephone Triage. This is a brand new resource that was released this year by Anthony J.Janetti, Inc, and endorsed by the AAACN!
So far, I have found this book to be enjoyable and educational. It takes you from how telephone triage came into being, where it is now, and where it is going. Along the way, they have included how to correctly run a successful triage program, whether it be in an office or a call center, the legal aspects of telephone triage nursing across state lines, and my personal favorite, true triage stories to learn by.
So far, I have used some of these stories in our staff monthly newsletter as a training tool, and our nurses have commented on how much they too have learned and how interesting they are.
This resource has been needed for a long time. There are several telephone triage books and resources available, but none puts the pearls and perils into the same perspective as this book does. I would encourage anyone to read it and use it as a valuable resource for their telephone triaging. I also think it would be a great book for someone who is interesting in entering this specialty area, and a valuable training resource for those new to the field as well.
I am encouraging our nurses to read it!

Real Telephone Triage

There are so many telephone triage companies now that it would be impossible to name them all, and I am definitely not here to say there is any one program that is better than another. However, has telephone triage gotten so complex that many have lost focus on what it really is?
I have seen complex programs, and have spoken with many experienced telephone triage nurses that tell me they feel like robots reading from computer screens. Systems have gotten so complex that they are not given the ability to actually use what they were trained to do, and that is be independent critical thinkers and use the nursing judgment skills they were trained with. Many of these nurses are now expected to be secretaries among other duties and track waiting times in urgent cares for instance. Is that really providing patient focused care?
What is wrong with being able to follow a protocol for questions to ask, to get the information needed to make a sound judgement of if the patient needs immediate treatment, or can it wait until the office opens? And, if there is not a protocol that fits, to be able to use nursing judgment to give sound advice? I know that I have spoken with patients who are grateful to be able to get appropriate advice from someone who can think independently from a computer screen, and I know the patients can tell when that advice is being read to them vs actually coming from a voice of experience and reassurance. Offices have verbalized that they appreciate personalized attention given to their patients from experienced telephone triage nurses.
Alot of money can be spent in some elaborate systems, and they sure look attractive, but I am proud to say that we ARE what telephone triage nursing is...Quality telephone advice given following standardized protocols, by caring, experienced triage nurses who go the extra mile to educate, advocate and direct the caller to the most appropriate next step of care. All completed without the complexities of navigating among many screens for one symptom.
Our nurses care about their callers, and many will tell you they will take patient focused care and the freedom to be a real nurse any day!!
It would be interesting to see how many other triage nurses feel the same.