Telephone Triage for Oncology Nurses

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Introduction

Much of the care of patients with cancer has shifted from the inpatient arena to the outpatient setting in the last decade. The traditional nursing role has been challenged by this change in patient care settings. Nurses continue to be educated and cultured in the inpatient hospital setting, yet many nurses find themselves practicing in the outpatient setting. Outpatient nursing employs many of the skills learned in the inpatient setting; however, there is a shift from the nursing-based model of practice to the medical model. Nursing Spectrum, an RN-led communications company, describes the desirable skill set for ambulatory nurses, including phlebotomy, IV therapy, triage and telephone advice, teaching, communication skills, autonomy, and independence ("Careers in Nursing," n.d.).

Telephone triage and providing telephone advice is a skill set that is key to ambulatory nursing. Telephone triage and advice are new to nurses as they move on to the ambulatory setting, and overall. Regardless of the nursing specialty (e.g., pediatrics, family medicine, oncology), nurses in outpatient clinics frequently find themselves performing assessments and providing triage and advice over the telephone. Telephone calls from patients are a major component of oncology outpatient nursing practice and should be taken into consideration when budgeting for and assigning staff.

Telephone triage is a growing practice within physicians' offices as healthcare providers seek ways to identify new cost-effective strategies. Telephone call centers have been designed to match the patient's needs with the appropriate resource. Nurses provide triage and advice to callers. Patients are calling more frequently for advice and/or counseling before requesting an appointment (Wheeler & Siebelt, 1997). Telephone nursing has become an everyday function of nursing care in a variety of settings. The types of calls received and the care provided need to be individualized to the setting, the patient, and his or her problem. Mastery of telephone triage has become a difficult yet necessary skill for the outpatient nurse. Office triage nurses must be knowledgeable about the patient, including his or her current and past medical history and social situation, and experienced in the nursing specialty, with an expert knowledge base of the usual disease states or conditions and treatment regimens. The nurse must possess good interviewing skills and well-developed telephone assessment skills (Kelley & Mashburn, 1990).

Oncology nurses are especially challenged in meeting their patients' needs over the telephone. A nursing assessment of a patient with cancer can be quite complicated. The cancer, as well as side effects from treatment with surgery, radiation, chemotherapy and biotherapy, can lead to a variety of symptoms. The nurse may be taken off guard by the patient's telephone call, as it can occur at any time. The patient's chart, with a complete medical and cancer history and treatment plan, may not be available when the nurse first responds to the call. (Tip: Have the secretary/receptionist locate the chart prior to transferring the call to the triage nurse.) The complex patient assessment is made even more difficult when the assessment is performed over the telephone because the nurse is unable to directly observe or examine the patient.

Nurses are direct care providers. They are educated and practice in settings in which they use their senses when assessing and caring for patients. As nurses gain more experience, they assimilate and process information through their senses so rapidly that they often are unaware of individual thought processes. This is commonly described as "intuition" or "a gut feeling." Regardless of how the nurse defines this ability, the thorough nursing assessment, including sensory observations, allows the expert nurse to make prompt and accurate decisions. This "intuition" often is lost when the assessment is performed on the telephone because of the lack of sensory input. The nurse cannot see, touch, or smell and must rely solely on verbal and listening skills. Furthermore, the nurse may be communicating with a family member or friend who is attempting to describe the patient's complaint.

It is not surprising that telephone triage can be a daunting task for an oncology nurse unless the nurse is well prepared. A systematic process, including written protocols or guidelines, complete and concise documentation, and processes within the busy practice setting, allows the nurse to give the required time and attention to the patient's call. Preparedness requires an in-depth understanding of oncology and oncology care and excellent assessment and telephone communication skills. Oncology nurses with years of experience and skill in telephone assessment and communication may develop a "telephone intuition" that allows them to ask a few pointed questions to quickly get to the root of the problem. They are able to hone in their assessment not only with their knowledge of the specialty but also their knowledge of the patient. These nurses will listen "between the lines," focusing not only on the patient's words but also the tone of voice. The expert telephone nurse can quickly identify the patient's anxiety, pain, or other symptoms, such as shortness of breath. However, for nurses who have not yet gained these skills, few resources are available.

The goal of this book is to provide useful tips for oncology nurses as they develop telephone triage or telephone nursing practices in their clinical settings. To date, there has not been a text that addresses the special needs of patients with cancer or the special skills required by the oncology telephone triage nurse. The authors hope this book will help both expert and less-experienced nurses. The purpose of this text is to provide "how-to" tips for telephone assessment, communication, and documentation as well as for the telephone triage process, including a sample of legal concerns and models of practice. The telephone guidelines and protocols are symptom-based and were selected to address the common complaints of patients with cancer. These protocols offer basic structure to handling telephone calls in an outpatient setting while providing continuity of care for the patient with cancer.

This text is designed to be a resource for oncology nurses who are learning the telephone nursing role. However, the expert nurse will find this text a resource to be used when educating newer nurses and a guide in how to develop a formalized telephone nursing practice in the clinic. The telephone symptom-related protocols will assist the expert nurse as calls arrive with complaints he or she has not handled in the past.

The following chapters will provide tips to improve telephone communication and a systematic approach to performing a telephone nursing assessment; information on legal issues and concerns; a discussion of telephone triage practice models; and an exploration of the history of telephone triage. Symptom-focused telephone protocols or guidelines are included to direct oncology nurses in the development of guidelines in their practice settings. It is essential that these protocols are not implemented without the review and approval of the physician(s) who manage the patients in the practice. These telephone protocols are written to serve as a guide to oncology nurses to meet the specific needs of their patient population.

Oncology nurses from across the United States have contributed these protocols in an effort to help other oncology nurses and improve patient care. Each protocol is credited to the nurse(s) by name(s) responsible for submitting a protocol that was used, at least in part, in the development of the published protocol. Thanks to each of these nurses who were so kind to share their expertise. This text could not have been accomplished without the sharing spirit and collegiality of oncology nurses.