CHAPTER 26

Issues and Solutions

LEARNING OUTCOMES

Upon completion of this chapter the nurse will:

ISSUES AND SOLUTIONS

Similar to providing direct care, telephonic care has a few issues and challenges. These issues can be categorized as being related to people, paper, or processes.

People

Clients

The issues with people occur at different levels. The most obvious is with the client. Clients are not always willing or interested in participating in a telephonic care program. They may have a variety of excuses ranging from “I have a doctor” to “what kind of care are you going to give me over the telephone?” Additional issues are provided next with suggestions to respond to the client.

As you spend more time with clients, you might learn of a few additional situations to add to this list.

Health Plan/Disease Management/Wellness Program

At times, you may have to talk with members of the client’s health plan or program to have information changed or validated. For example, a client adamantly denies having a health problem, yet the client still presents in the call queue with the problem. You change the information in the computer documentation system and save the information, but the next day the client is still identified as needing to be contacted for the health problem. It seems the only way to successfully disenroll the client is to call the health plan to have the client physically removed from the health plan’s end.

When you finally get through to someone at the health plan, the person tells you that there are several claims for the health problem. You have already talked about the testing with the client and the reason being to rule out the health problem. The client is not prescribed any medication for the health problem and is not going to be receiving any treatments. The health plan individual may not be happy with you; however, do not give up—expect to have the client disenrolled.

Keep in mind that people who are working for the health plan most often field calls from disgruntled enrollees. When trying to understand a charge or a claim, the enrollee can become angry. Health plan employees may sound harsh when contacted, which could be because they are expecting another argument. There is no need to argue. Disenrolling the client from the plan is saving the health plan money and not the organization you work for.

Coworkers

Unfortunately, the profession of nursing has a history of bullying and incivility. This might even be a reason for someone to leave bedside care and seek employment as a telephonic nurse. Even so, there might be situations in which incivility rears its ugly head in the telephonic care environment.

This information is not being provided as a warning but rather to provide an explanation. At times, the organization may be challenged to complete a large amount of work in a limited period of time. The number of staff available to provide care might not be sufficient to achieve the care call goals. The leadership staff have been notified that the health plan/disease management/wellness program expects a report showing the number of enrollees contacted and the anticipated day/time for the next call. Dialer reports are being run hourly to measure the success of the staff in meeting the expectation, and the leadership staff are wringing their hands instead of cracking a whip.

Now, bring this situation to the telephonic nurse level. The nurse is in a Welcome call dialer queue for individuals with diabetes. The health plan expects all demographics to be updated, medications entered, and the physical assessment started. In addition, at least two patient teaching tools should be ordered before ending the call. In order to meet the organization’s goal for the client contacts for the day, each one of your calls should last no longer than 6 minutes so that each nurse contacts 10 clients every hour.

An immediate knee-jerk reaction is “this is impossible,” and you might be right. Sometimes it takes 6 minutes to convince a client to participate in the program, even before any validation of demographics occurs. So, right now, the health plan is putting pressure on the organization, the leadership staff is stressed and studying dialer reports, and you, the nurse providing the calls, are told to stop talking so much and just get the information the health plan needs now. Someone is going to react negatively to all of the stress.

What you can do should this occur is this: stay calm, analyze how much time you are spending on “small talk,” and possibly begin the call with the client with a statement such as “I won’t keep you longer than 5 minutes today. Our next call can be longer, but I don’t want to take up too much of your time.” This sets the expectation with the client that the call will be short. You can move through the demographics. Then ask about medications such as “Because you are in our diabetes program, do you take insulin or another medication for that every day?” After you get the important medication for the primary health problem you can ask “are there any other medications that you take such as something for your heart or blood pressure?” Asking these direct questions keeps the client on track. You can end the medication portion of the call by asking a general question such as “is there anything else that you take daily such as acetaminophen or vitamin supplements?” Within a few minutes, the medication list is complete.

This leaves starting the assessment and ordering patient teaching tools. A good opening for this might be “do you have any other health problems or symptoms that you experience every day?” This gives the client the opportunity to focus on what is the most important to them. Depending on the answer, you can document this information in the appropriate area on the physical assessment. In preparation to end the call, you can then ask “how about if I send you some information to help you manage your diabetes? This would be a general fact sheet with some pointers that you might find helpful. And while I’m at it I’ll add another sheet that focuses on the type of medication you take. Because you will get these materials in about a week, how about if I schedule your next call for 2 weeks from now? That way you will get the material and have a chance to look it over before I call back.”

Keep in mind that this dialogue is only a suggestion; however, it has been used successfully by other telephonic nurses.

Even when everyone is doing their best during a stressful time, tempers can flair. One nurse overhears someone else say something that is incorrect or was supposed to be changed a week ago. Bickering occurs and everyone stops talking to hear what’s going on. Unless you are directly involved, stay away from the problem. Listen to what the issue is to make sure that you are not making the same error but otherwise do not get involved. The team leader will intervene and settle the situation. The nurses involved may be testy with each other for a while, but in time that will fade.

The amount of bullying and incivility that occurs in a telephonic care environment is minute compared to the extent of the issue with bedside care providers. Knowing that it can occur and the reasons why helps prevent it from happening in the first place.

Paper

Even though the work of telephonic care occurs with a telephone and computer, you will accumulate a large amount of paper resources. You will have your orientation manual, copies of health plan guide sheets, samples of patient teaching tools (or possibly copies of every tool), cheat sheets, lists of resources, and contact telephone numbers. There is no possible way for you to miss something, right? Not necessarily.

Work in a telephonic environment is fluid. Things change. The health plan adds something and takes something else away. The organization adds something to a policy but deletes steps from a procedure. A new feature is added to the computer documentation system, and cheat sheets are missing a few steps. In other words, all of the paper needs to be updated.

The team leader makes copies of the changed pages with the intention to distribute them to all team staff members. A situation occurs, and the new pages are placed on a desk. Hours later, the team leader returns to the desk to find the pages missing or moved. Who received the updates? Who still needs the updates? Is there time to make more copies to distribute before the updates take effect? What about the people who work part time and won’t get the updates until the weekend? Who is going to help them understand the updates? What should be done first?

Static (paper) resources do not fit well with a fluid environment because of the frequency of changes. The organization might implement another approach: place all updates on a shared computer file, and then send a group e-mail to all staff informing of the changed document. The staff can then either keep the file on the computer hard drive or print it out to replace the other static page that is outdated.

For major policy or procedure changes, each manual should be updated with the correct information; however, every staff member does not need a personal copy. A list of the changes to keep the staff informed is sufficient.

Processes

This brings us to the final issue that can create challenges in the telephonic care environment—processes. Process changes are the major reason why the paper issues occur. Processes are explanations of how to “do something” or the “work” of providing telephonic care. Processes are reviewed and practiced in orientation. Processes are mastered when working with the computer documentation system. Processes are essential because they standardize actions to improve efficiency and effectiveness.

When a process fails, things can quickly get out of hand. Someone needs to take the time to go through the process to see which step or steps are out of sync or causing issues. Then, new steps need to be identified to replace those that no longer work. Once the new steps are added, the process needs to be tested to make sure that no other issues occur. Finally, the new process is complete and ready to be distributed to all for immediate implementation.

Depending on the process, identifying, revising, and retraining can take hours, days, or even weeks. While the process is being improved or changed, tempers can flair and anxiety builds. Staff become concerned, and team leaders are not happy.

One way to reduce the effects of process issues is to expect them to change. Many nurses have said “I no sooner learn how to do something when it changes and I have to learn how to do it all over again.” This is the nature of telephonic care. Fluid environments are constantly changing. And you might not feel like you have mastered anything for quite some time. Providing care in this type of environment is not like mastering the preparation and provision of injections or calibrating intravenous fluids in a flash. Those skills do not change. However, the intricacies of telephonic care can and will change. But, what does not change is the goal of contacting clients to discuss health needs and approaches to maximize wellness and meet personal goals.

HANDLING THE STRESS

Remember the days when clients were falling out of bed, intravenous lines were being pulled out, and doctors were yelling at you because orders weren’t completed yet? Your worst day as a telephonic nurse does not even come close to the stresses of a bedside nurse. Remember this when you become anxious and wonder if you made the right decision to become a telephonic nurse.

You made the right decision. You are:

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