January 2, 2018

Communicating With Providers Over The Phone

I've received many messages from nurses who are having problems communicating with providers over the phone. As a nurse who works nights, this is something that often occurs and not during optional time frames (between midnight and 5 AM, usually). I must wake up providers, and promptly present clinical pictures, along with any additional details needed. As the notification time isn't ideal, emotions can run high. Just because you are in healthcare doesn't mean the individual is emotionally intelligent and is open to validating your concerns. Telephone communication, in my opinion, is a barrier, and you must be able to remain professional regardless of the emotional display presented on this other end of the line. Here are a few tips to help you communicate when you must advocate for your patient.

The Picture 
I've talked to many providers, and the number one reason most providers are annoyed when they are called in the middle of the night is due to nurses being unprepared. For example, a nurse calls cardiology about chest pain x 30 minutes. The provider asks questions related to the quality, duration, and associated symptoms related to the chest pain episode. The nurse is unable to answer these questions, and therefore, the provider can't formulate a prognosis or plan of care. The goal of the phone call is to create a clear clinical picture, but sometimes, this isn't achieved for one reason or another. This is why I tell nurses to always have the paper chart (if applicable), and electronic chart open when you call the provider. Some things you won't know and that's why you have the chart open and ready for any follow-up questions. Also, the nurse should ask the patient as many follow-up questions as possible before the call is placed. The aim is to have all the resources at your fingertips. You want to create the clinical picture, get orders promptly and to decrease any back and forth dialogue. Communication is excellent but the longer it occurs, the muddier it gets. The conversation shouldn't run on for 20 minutes, this isn't a personal phone call.

The Orders 
If you receive orders, perform per your institutional protocols and initiate them as soon as possible. The trouble occurs when there is a concern or problem, and you're not given orders. This often happens where I work. For example, a patient's heart rate is 130 beats per minute, sustained and the patient is asymptomatic. I call the provider and am told, "To continue to monitor. No orders will be given at this time." When this occurs, I confirm the instructions with the provider for a second time over the phone and alert the charge nurse of the update. The purpose is to make sure the proper individuals are notified and are aware of the patient's condition. Because eventually, the charge nurse will ask you why your patient's heart rate is elevated. With the notification process, all parties are aware of your attempt to obtain orders. As for documentation, I'd document somewhere in the chart that notification was given. I'd chart the time of the initial notification (call to the answering service), the time the phone call was returned and the subsequent orders or instructions. Which means for each phone call, two documented events are needed.

Here is an example: 

03:15 AM: Nursing called cardiology regarding sustained, heart rate of 130-135 bpm, patient asymptomatic. 
Change in patient condition message left with after-hours service (Ashley), nursing waiting for return call.
The episode started at 03:10 AM, event ongoing. Charge nurse notified. Nursing will continue to monitor.

03:25 AM: Cardiology returned nursing phone call. Episode, chart and vital signs reviewed. 
No orders given at this time, nursing will continue to monitor. Charge nurse notified. 

The Emotions
Now even if you are prepared, you might encounter a provider who can't control their emotions. This often occurs on the night shift as many on-call providers are sleeping or just not in the mood. First, understand this isn't personal. This is merely an upset person annoyed you're calling them. Is it right? Of course not, but don't over analyze it. They're dramatic, that's it. Second, don't feed into the negativity and don't allow it to affect you professionally. If you're calling about a concern, regardless of their reaction, continue the SBAR process. I've had providers cut me off mid-sentence and yell, "This isn't important!" I calmly state, "So at this time you want nursing to continue to monitor, and you're not providing orders at this time, correct?" I need them to understand the tantrum doesn't affect my job, and I'm calling for a reason. The longer they ramble on and complain, the longer the phone call will take. Do you want to go back to bed? Answer my questions, and we will be finished. Plain and simple. I'm not concerned about you being upset. Your emotional station doesn't concern me. What does worry me is my patient and the need to update based on my scope of practice.

That's really it. It's your job as a nurse to notify providers when a change in patient conditions occurs, you need to clarify orders, or a critical result is posted. Don't worry about all the emotional stuff. This is our job, and they too have a job. If you're on the clock, you can't be mad you're needed. I have a son, he is three years old with autism. He's taught me to have patience when people are emotional. Because it's time-based, it will pass. Just take a deep breath, stay professional and do your job to completion.

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