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 be bidirectional (i.e., 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.

Gustafsson and Eriksson (2020) completed a systematic literature review to identify factors that indicate quality in telephone nursing. Good communication was identified as a necessity since the nurse cannot observe the caller’s reactions and nonverbal communication cues. Effective communication requires a calm environment that is free of distractions. The nurse ensures that the caller understands all aspects of the conversation and has an opportunity to ask questions and express the ability or inability to carry out the plan.

At the bedside, speech, smell, touch, sight, and emotional cues paint a 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).

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

The nurse is responsible for interpreting the needs of the caller. Whenever possible, the nurse should speak directly to the person who is experiencing the symptoms. If there is a misunderstanding, the assessment could be incorrect or the advice may be incorrect or not followed (Gustafsson & Eriksson, 2020). 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, with some older callers, due to severity of symptoms, or with poor historians. This strategy will improve the quality of information collected, foster trust and compliance, and expedite the call.

Allow Enough Time

Adequate communication requires 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. It has been found that faster decision-making and shorter call length may increase the risk of poor quality of communication (Graversen et al., 2020).

A landmark study compared performances of pediatric nurse practitioners with pediatricians (Goodman & Perrin, 1978). The authors discovered that pediatric nurse practitioners spent significantly more time per call than physicians and were identified as warmer and more open to questions, leaving callers feeling more satisfied.

Use Plain Language

It is important to use concise plain language. A statement such as “It is possible that your 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 is in plain language if the individual can:

• Find what they need
• Understand what they find the first time they read or hear it
• Use what they find to meet their needs

Common techniques to reach those goals include using:

• “You” and other pronouns
• Active voice, not passive
• Short sentences and paragraphs
• Common, everyday words
  (Plainlanguage.gov, n.d.)

Implement Teachback Methodology

Teachback is a method in which patients describe information they have been given, using their own words. When this approach has been used by health professionals, the following benefits have been demonstrated:

• Improved patient understanding and adherence
• Decreased call backs
• Improved patient satisfaction and outcomes

“Chunked and checked” is a teachback technique that can be employed during a telephone encounter. Instead of reading a list of interventions that the patient could implement at home, the nurse 1) breaks down the information into small segments (chunk) and 2) asks the patients to teach it back (check). This process can be followed throughout the call and not delayed until the end of the call.

For instance, the caller’s understanding of the advice, worsening symptoms, and when/where to access additional care should be confirmed through an inquiry such as, “We have gone through a lot of information, tell me what you are going to do? Are you comfortable with this plan?” (Anderson et al., 2020; AHRQ, 2020).

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. Leading questions should be avoided in order to prevent obtaining 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. Therefore, when protocols are embedded in an electronic health system, caution must be used to reduce the assessment to a series of questions within the system. A thorough assessment must be completed prior to the selection of the protocol.

When nurses use computerized decision support systems that require a yes/no response, the ability to assess accurately and apply critical thinking is limited. The rigid use of protocols has been criticized because it requires the use of primarily closed-ended questions, which does not allow for a holistic approach and carries the risk of missing important patient information (Graversen et al., 2020).

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 older adults, 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.