By Marci Lawing, RN, BSN and Ravi Raheja, MD
1. The Importance of Listening Skills
Listening! Many nurses would say they are good listeners, but in reality, most are taught to let the machines tell them how the patients are. Hospital nurses are often too busy checking vital signs, documenting, watching the patient’s breath, and giving medications to actually listen to and focus on what patients are saying. Telephone triage nurses on the other hand, cannot use their vision, smell, or touch: they have to listen to the patient to determine the seriousness of the patient’s condition. Nurses in telephone triage and patient advice lines must be excellent listeners. Triage nurses must be tuned into the caller’s tone of voice: is it panic stricken, tired, worried, or mad and frustrated. Why is the baby crying or the husband yelling or doors slamming? Is that wheezing, stridor or constant coughing? We have to listen to the words the patient/parent is saying, but also to how they are saying it. Not all information given is relevant: the parent/patient is telling you what they think you want to hear. We must remember that it is not up to the patient to tell you everything you need to know. The triage nurse must accept the burden and responsibility to ask the right questions and to gather enough information to make a safe decision. Much of this comes from experience and practice. The triage protocols that nurses use are tools to help in the decision making process, but it is truly the triage nurses’ listening and critical thinking skills that are going to catch those subtle sounds and clues that are so important.
2. The patient who loves to talk
Some patients tend to ramble on about any and everything and tell the nurse what they think the diagnosis is. Nurses handling phone calls for a nurse advice line need to be able to direct the caller and learn to take control back of that call quickly! These callers have had time to rehearse what they are going to say and often, they have it written down so they don’t forget to tell the triage nurse. Timing is everything, such as waiting until the caller takes a breath (they have to come up for air, right?) and then jump in, tell him/her you can and will help them but need to ask a few questions first. Sometimes asking the patient to please hold for a few moments gives the caller time to stop talking and the nurse time to regain control of the call. It is a fine balance between being a good listener and letting the patient continue talking about non-relevant details.
3. Choosing the Right Guideline
I heard once during a conference that “If you get on the wrong train, every stop along the way will be wrong.” If you pick the wrong guideline, all of your dispositions along the way are going to be wrong and you will end up at the wrong destination. Patients can present with so many symptoms, “where do you start?” This process goes back to the fundamentals of nursing: Airway, Breathing and Circulation. Which of the problems is likely to result in the highest acuity/disposition? That is where the telephone triage nurse should start. Sometimes multiple guidelines are needed to fully assess a patient. Lots of practice and reviewing the guidelines will help, but also learning how to use the “keyword” search option helps broaden the search enough so that the nurse can find an appropriate guideline.
Triage nurses show empathy in a different manner from floor nurses. They can’t touch or show our facial expressions to the patients. Nurses may find this difficult. Telephone triage nurses have to learn to express empathy in their voice, tone and in the words that they say. It can feel awkward at first, because many times a nurse will just “sit” with a patient and give support and comfort. Triage nurses must keep the conversation flowing. Using reassuring words and sympathy can help build trust and let the patient know you are listening. Sometimes a simple “I am so sorry that you are going through this” is all the patient needs. This blog concludes our series of tips for training telephone triage nurses. Feel free to make comments and leave us feedback if there are any topics that you would like us to discuss. And don’t forget: if you like the article, please share it with other triage nurses, triage managers and anyone else looking for more information on how to be an effective nurse triage.
About the authors: Ravi Raheja, MD Medical Director and COO of TriageLogic, is a board certified pediatrician who saw a need for effective triage services and founded TriageLogic in 2005. Marci Lawing, RN, BSN is a nurse manager with TriageLogic and handles hiring, training and nurse triage.