COMMUNICATION
The clinician performing telephone triage is, first and foremost, a communicator. The manner of communication is as important as what is communicated. Telephone triage requires almost instantaneous rapport between caller and clinician to facilitate effective data collection and patient compliance. Nurses must inspire, negotiate, persuade, and engender trust. “Telecharisma” is a “magical” characteristic of telenurses. From their first words of greeting to the way they listen, respond, and ask questions, charismatic nurses working in the field of telephone triage demonstrate warmth, caring, and trustworthiness.
A patient-centered approach consists of an understanding response that fosters a trusting relationship, facilitates eliciting information, and enhances patient satisfaction. How clinicians treat patients influences how patients feel about them. Hostile, abrupt, impatient, and judgmental responses may tend to dishearten and frustrate patients and make them withdraw.
Successful communication requires a sender, a message, a mechanism, and a receiver. For the message to be complete, information usually has to flow in both directions. Experts have found that too little or too much information impairs critical thinking and diminishes the chances of the message being received and understood. With telephone triage, the prospect of too little information is increased due to lack of sensory input and information.
At the bedside, speech, smell, touch, sight, and emotional cues paint a rich picture of the patient’s condition. On the phone, communications are limited to verbal and emotional cues. The risk of miscommunication is great. Although it is possible to gain limited tactile and visual information gathered by proxy from callers, nurses receive, analyze, solve problems, and instruct without observing the patient (Mataxen & Webb, 2019).
Thus, because the “signal” is weak, barriers that in person are not very formidable can become nearly insurmountable on the telephone. Messages may be impaired by lack of trust or by unexplored feelings, needs, and biases. Patients’ and nurses’ beliefs, attitudes, and perceptions of symptoms become obstacles in themselves. Ineffective communication in health interactions is a common root cause of error, and it may lead to increased legal liability and patient harm (Guttman et al., 2018).
In telephone triage practice, nurses can facilitate effective communication by closely attending to and receiving messages, clarifying or asking for detail, reflecting, and paraphrasing to check accuracy. Following are several communications best practices to enhance critical thinking.
Speak Directly with the Patient
Many errors occur due to failure to speak directly with the patient. Many pitfalls can be avoided by talking directly to the patient when possible, although this may not be feasible with children under the age of 8 years, some older callers, or poor historians. This strategy will improve the quality of information collected, foster trust and compliance, and can expedite the call.
Allow Enough Time
When it comes to “talk time” in telephone triage, there are no shortcuts. Adequate time enhances decision-making and critical thinking. Current standards show that an average timeframe for a telephone interaction is 8 to 10 minutes or more, depending on the type of call and caller (Raheja, 2018).
A landmark study compared performances of pediatric nurse practitioners with pediatricians (Perrin & Goodman, 1978). The authors discovered that pediatric nurse practitioners were judged to be warmer and more open to questions, left callers feeling more satisfied, and spent significantly more time per call than physicians (RNs, 5 to 7 minutes; MDs, 3 to 5 minutes).
Adequate communications require adequate time. If callers perceive the nurse as “time driven,” offering few explanations, and making little attempt to build rapport, communications can deteriorate. Some callers, dissatisfied with a brief interaction and lack of emotional support, will fail to follow the advice.
Use Lay Language
It is important to use concise lay language. A statement such as “My diagnosis is that a viral syndrome is causing a flu-like syndrome. Use acetaminophen for this viral syndrome, increase fluid intake, and monitor output” is unhelpful to the caller. This might instead be stated as “From what you have told me, your child appears to have flu-like symptoms. Aspirin can be dangerous for children under 16 years of age. Use acetaminophen (such as Tylenol) instead.” Instructions should be kept to a minimum, using short, directive sentences.
“Plain language” is communication patients can understand the first time they read or hear it. Written material in plain language:
- Is written at the 5th- to 8th-grade literacy level
- Is consistently and logically organized
- Uses active voice
- Uses short sentences
- Uses common, everyday words
Plain language is defined by results. It is easy for clinicians to read to patients and for patients to immediately understand and use (Plainlanguage.gov, 2015).
Use Open-Ended Questions
Open-ended questions provide for better and more reliable data gathering by encouraging the patient to perform the work of describing symptoms. Asking leading questions—a flawed technique often related to being time-driven—often yields faulty data.
Leading questions cloud the picture by providing the answer in the question. Such questions—“Is the pain severe?” “Are you having bloody stools?” “Are you having difficulty breathing?”—usually elicit yes or no answers. Open-ended questions—“How would you describe the pain?” “What are your stools like?” “What can you tell me about your breathing?”—eliminate yes or no responses.
In telephone triage, most data collection should be gathered with open-ended questions.
There are several exceptions to the policy of utilizing open-ended questioning. On crisis-level calls, where decisions must be made within seconds, leading questions are appropriate: “Is the victim conscious?” “Breathing?” When an immediate disposition is imperative, open-ended questions are too time-consuming.
In calls from children, frail elders, and poor historians, facilitative questions can be used, such as: “Is the pain better, worse, or the same as it was yesterday?” “Is the bleeding dark red or light red?” This is a compromise between open-ended and leading approaches that may still yield better data than leading questions.
CASE
A wife placed a call to the nurse triage line at a primary care clinic, stating that she thought her husband might have the flu because he had a high fever and was not responding to Tylenol. The nurse provided the patient an appointment that same day. The patient was seen and diagnosed with seasonal flu.
The wife called again the next day stating that the patient had a “pounding headache and stiff neck.” He was once again given an appointment in which the physical exam was unremarkable.
Day 3, the wife called again, stating that she was concerned about her husband because “his fever was still 102.9 °F and not coming down with Tylenol.” When asked if her husband had a stiff neck, the wife stated “no” and offered no new information.
The nurse, sensing that perhaps the situation was more urgent (this being the third call from the patient’s wife for the same problem), asked to speak directly to the patient. When the nurse spoke with the patient directly, the patient related a history of continuing severe neck pain, headache, and fever, prompting the nurse to instruct the patient to go to the ED immediately to be further evaluated. The patient was subsequently evaluated in the ED and diagnosed with meningitis.
Discussion
In this case, because the nurse spoke directly to the patient, a clearer picture of the clinical situation emerged. The nurse recognized the red flag of repeat phone calls for the same problem. This case was further complicated by the fact that his primary care physician had also evaluated the patient, and this may have given the nurse a false sense of security (an example of a “red herring”).
If the nurse had failed to speak directly to and assess the patient, the disposition may have simply been for monitoring and self-treatment of the patient’s assumed flu-like symptoms. The patient may have further deteriorated, resulting in a significant neurological event.