It's Your Call: The World of Telephonic Nursing

Nanette Lavoie-Vaughan, ARNP-C, MSN
Sandy Keefe, RN, MSN




With telephonic nursing, RNs use their best assessment skills to make
reasonable deductions.

On a cold winter morning in Broomfield, CO, Cindy Wendling, RN, BSN, walks
into the McKesson Health Solutions Care Center. Heading to her workstation,
she boots up her computer and takes a few moments to ergonomically
arrange the computer keyboard, mouse pad, telephone headset, and
resource materials. For the next few hours, Wendling fields a steady stream of
inbound calls from patients seeking advice from her, the telephone triage
nurse.

She fields calls from mothers about children with rash, cough, or vomiting;
queries that warrant further investigation by a healthcare practitioner; and
every now and then, a true emergency: crushing chest pain or neurological
changes that suggest stroke. Wendling handles the calls with ease, referring
to a sophisticated set of algorithm-based protocols on the computer that guide
her to an endpoint. As part of the call, she may provide approved home care
advice, recommend a call to the primary care physician, or even urge the
caller to contact 911. After a moment or two to wrap up the details on the
computer, Wendling is on to the next caller.

Later that evening, Barbara Mallari, RN, BSN, logs on to the computer system
at Health Net Federal Services in Rancho Cordova, CA. As a healthcare finder
on the after-hours line, she answers calls forwarded from military bases
across 11 states. Mallari can authorize treatment at base hospitals or clinics;
when no military treatment facilities are nearby, she uses the Internet to locate
nearby civilian resources. Many of Mallari’s calls are from members of the
armed forces who are traveling away from their home base. She also spends
a good deal of time talking with military wives, many who are the sole
caregivers for their children because their spouses have been deployed. Like
Wendling, Mallari has calls that range from the mundane to the emergent.
Although she doesn’t officially triage the situation, “You do need to have a
sense of what’s a 911 or ER call and act accordingly,” she says.

Mona Mathewson, RN, MSN, provides quality assurance and education to
clinical nurse consultants at a LifeMasters® Supported SelfCare’s call center,
which is located in a suburb of Sacramento. The consultants, who provide
telephonic disease management services, have a set list of appointments
each day similar to clinic appointments. Throughout the day, nurses
scheduled outbound calls to program participants with congestive heart
failure, diabetes, coronary artery disease, hypertension, chronic obstructive
pulmonary disease, and asthma. Although the calls focus heavily on health
teaching, program participants are also encouraged to monitor and report vital
signs for review by the nurse consultants. Changes can be picked up early,
often averting ED visits or hospitalization.

What About Patient Contact?

“The callers are so sweet and respectful of nurses,” says Mallari. “It’s
important to listen to the message behind their words. I like working here —
our goal is actually to ‘delight’ the caller. Not just to do a good job, but to
delight them with our interest, responsiveness, and level of service.”

“You have to listen to what they’re saying with their emotions as well as their
words,” Wendling echoes. “Many times, I’ll say something like ‘I hear you’ or “I
see what you’re saying.’” Then there will be a moment of silence, and the
person I’m talking with will get all choked up or give a big sigh.” When asked if
she missed direct patient contact, Wendling seemed surprised. “You know, I
develop a good, warm rapport in the short time I’m on the phone. I joke and
commiserate. I get that kind of empathetic communication that means so much
to me as a nurse.”

Autonomy Issues

Rather than taking away the nurse’s autonomy, the software programs used in
telephonic nursing actually enhance the nurse’s ability to make good
decisions, says Wendling. “The information is all there, but you can override
the endpoints by using good nursing judgment and providing sound rationale.
The computer never makes the final decision — that’s why RNs are so
necessary in this environment. We have to use our best assessment skills and
make reasonable deductions. Telephonic nursing is not a field for someone
who needs to be constantly guided,” she says.

The Downside

When asked about the less enjoyable aspects of their jobs, both Mallari and
Wendling mentioned lack of follow-up with the patient. “In the hospital,”
Wendling says, “you could always check the next day to see how things went
with your patients. Here, we do some call backs to check on outcomes, but
that’s limited. Mathewson, however, makes regular calls to participants and
enjoys follow-up as one of the benefits of disease management nursing.

As usual, weekends, holidays, and shift times can be issues. Wendling works
every other weekend and is obligated to every other holiday. Mallari chooses
to work every weekend to be home with her children more during the week.
She selected an evening shift to accommodate her family schedule. Wendling,
on the other hand, has the day shift of her choosing. Disease management
nurses, Mathewson explains, work primarily during day and early evening
hours, with lighter coverage on weekends and holidays.

Bringing the Right Skills to the Job

All three nurses describe nursing assessment and patient teaching as the
bedrock of telephonic nursing. “You have to bring a true passion for health
education to this position,” Mathewson says. “You need to evaluate how ready
the person is and what he needs to change behaviors. Then you make a real
impact on quality of life.”

“You absolutely use more nursing skills to communicate on the phone without
the nonverbal input,” Mallari concurs. Wendling cites a solid grasp of normal
anatomy and physiology, as well as pathophysiology of common disease
states, as key requisites for telephone nurses. “You need to be comfortable
thinking on your feet and making decisions,” she says.

While telephonic nursing doesn’t require high-speed typing, most call centers
look for nurses with basic keyboarding skills, familiarity with use of the mouse,
and comfort with e-mail. Most call centers have productivity goals and
regularly audit nurses’ calls. “You know, it’s no big deal,” says Wendling. “The
software is quick, the supervisors are reasonable, and you get comfortable
with the flow and the productivity requirements.” For disease management
nurses, Mathewson says, “While there are appointment times to keep, the time
is sufficient to give participants what they need.”

“Nurses also need to be comfortable with the idea that others can hear what
they’re saying — the nurses in surrounding work stations, or supervisors
listening to calls. If you’re a nurse who never wants feedback, this isn’t the
place for you,” says Wendling.

Exploring Telephonic Nursing

Nurses who want to find out more about telephonic nursing may want to take a
home study course. Another option is to contact local companies who operate
call centers, and ask for an opportunity to come in for a tour and a chance to
talk with the nurses.
Nanette Lavoie-Vaughan, M.S.N., APN