How to Give Good Phone

by jparadisi

painting by jparadisi 2013

Nurses spend lots of time on the telephone. So much, that I believe How to Give Good Phone should be taught in nursing school as a subtopic of therapeutic communication. For the rest of us, here’s a crash course developed over the years.

We all remember that communication has three components: sender, receiver, and a message:

Sender. Nurses call other departments for a variety of reasons. We call material supplies requesting special bio-occlusive dressings for patients with adhesive allergies. We call the pharmacist with questions about unfamiliar medications. We call physicians requesting new orders when a patient isn’t doing so well.

Receiver. Nurses also receive phone calls. Physicians call to admit patients. The lab calls, announcing we didn’t send the blood tests in the right colored tubes, and they need to be redrawn.

Someone we don’t know calls, asking if his mother, who we also don’t know because she is not one of our patients, is done with her appointment. When we ask him for more information to find her, the caller misconstrued this to mean we’ve misplaced his mother, which brings me to…

Message. Clarity begins with the sender. Intuitively, message should be the simplest part of the communication process, but in fact it is often the most difficult, especially over the phone, where visual information is lost to the sender, the receiver, or both. This loss of visual information is what makes reading back a telephone order by a nurse to a physician a critical component of that type of communication.

Here’s another example: you’re calling in a hemoglobin value to the physician. If the lab value indicates borderline for anemia, but you strongly feel the patient would benefit from a transfusion, you would want to include the subjective symptoms you see at the patient’s bedside: headache, shortness of breath on exertion, and increased fatigue. Knowing that you are going to suggest a transfusion for this patient based his clinical assessment before pushing the phone number keeps the message on track and focused on the patient.

I’ve been the sender of a message to a receiver (not a physician), who appeared confused about our roles. She did all the talking.  This obstructed my message. Perhaps anxiety caused her to blurt out lengthy commentary irrelevant to the subject of the call, I don’t know. I let her talk until she needed to take a breath, then interjected, “May I give you more information?” each time this occurred, until finally my message was delivered, and we got to work on the real problem.

Why would I devote so much time to this phone call? Because I needed the services of the receiver on the other end of the phone. Interrupting her abruptly to tell her how busy I am, using a smug tone of voice, or getting angry would simply slow down progress, and patient care. Giving good phone requires a purpose, an intended outcome, and patience.

What is your biggest peeve about telephones at work? How does your unit help patients seeking information by telephone?

A version of this post was previously published on TheONC.org.

Managing Patient Anger

Recently, I received an invitation to submit jpegs of my paintings to a juried art exhibition. While looking over the gallery’s past exhibits on their website, I wondered why they invited me.

Punch & Judy (detail) by jparadisi

Punch & Judy (detail) by jparadisi

The paintings I make don’t reflect the style of work this particular gallery exhibits. The mismatch started me thinking about the concept of curation, and how it applies not only to art, but also to nursing.

The definition of curate is:

Verb [with obj.] select, organize, and look after the items in a collection or exhibition.

Nurses curate insofar as we organize the care, and advocate for, a random collection of patients during our shifts. Usually, we do not select (jury in) these patients. Instead they are admitted by a physician or nurse practitioner, and assigned by a charge nurse, or whoever makes assignments on the unit.

The bedside nurse takes this collection of patients and curates (organizes) the mêlée. Most  shifts it works, but occasionally, a mismatch of personalities occurs.

I’m talking about those times when a patient doesn’t like me. If I don’t take immediate steps towards alleviating the situation, they become patients I don’t like either, and I am never pleased with this outcome.

Not every patient is a nice person. Disease and trauma are kind of blind in that regard. However, most patients are so kind, and patient, that it always catches me off guard when one is downright rude.

Here’s a list of things I’ve observed about angry patients:

  • No one is a voluntary patient. Anger is a normal response to an unexpected trauma or diagnosis.
  • No matter how personal their words, they are mad at their predicament, or at life in general, not you. Don’t take or make it personal.
  • Often anger expresses helplessness. For example, many elderly patients are also caring for a spouse or adult child with disabilities. Their anger often expresses anxiety that they are now unable to provide for that family member’s welfare.
  • Transportation to and from appointments contributes to the anxiety of patients dependent on other people for transportation. This may be expressed as anger if follow up appointments or ongoing treatment are prescribed.

Here are a few suggestions for coping with patient anger:

  • Often, simply arranging for the needs of the patient’s disabled charge diffuses the situation.
  • Call in spiritual care and social services to counsel the patient, and help arrange transportation needs.
  • Effective communication requires a clear message. Evaluate your approach. If a patient reacts during their assessment, consider re-wording the questions. You may be using words or a tone of voice they consider offensive, and are reacting to that. They actually may not understand, and are not trying to be difficult. The patient doesn’t know you’ve worked three 12-hour shifts in a row, and haven’t had a meal break yet. The reality is, that’s not a patient’s responsibility.
  • Frame disagreements regarding an angry patient’s care on the foundation of their safety. By keep this perspective and remaining professional, it is easier for your manager to support and defend you from unreasonable patient complaints.
  • Do not placate angry patients by promising special treatment outside of patient safety or professional boundaries. This sets up the next nurse for trouble. Care plans for any patient need to be sustainable for everyone providing care.
  • Never start an IV or access a port on a patient when you are angry.
  • If all else fails, request another assignment. Some clashes can’t be settled rationally.

What suggestions do you have for managing personality conflicts with patients?

Let Me Tell You One More Thing You Already Know

Intubated (Baby with a Breathing Machine) mixed media on vellum by JParadisi

Maybe it happened because I was tired after working a string of long, busy shifts.

Maybe Mercury, the communication planet, went retrograde last week.

Last week I wasn’t as good of a communicator as I would like to be.

I am one of those nurses who learned something in the Therapeutic Communication module of nursing school. Before you judge me as the nerd I kinda am, I do not go around repeating, “What I hear you saying is…” Such phrases are not what someone wants regurgitated back at them. The phrase is a tool, not a mantra. Instead, I learned to carefully listen to the words a patient uses and watch for any mismatch of those words in their body language. Then I speak to the body language. As a visual artist I first think in images, then put the ideas represented by the images into words, like a songwriter fitting lyrics to a melody. For me, the pictures come first, then the words.

Here’s what happened:

A colleague introduced me to a nursing student whose next clinical rotation is pediatrics. She told her I was once a pediatric intensive care nurse, and the student asked if I had any pearls of wisdom to share. While I am not so vain to believe my words possess a cure for the deep wounds of a human soul, I am vain enough to believe I occasionally have something insightful to say. So I offered this advice:

  • Always consider the parent-child unit as your patient
  • Even if a parent doesn’t know pathophysiology, they know their child better than you do.
  • The smaller the patient, the more important it is that you get it right the first time.
  • If you are unsure of what you are doing, find a nurse who does know. Stick close to your preceptor.

I finished and saw the glazed look on the student’s face. Her shoulders already turned away from me. She didn’t really want my advice; she was only being polite. David tells me when he sees this look in the eyes of the pharmacy students he precepts, he adds, “Let me tell you one more thing you already know.” She was not my student, however, so I shrugged it off.

A few days later, I was starting an IV in a patient. I had started IV’s in this patient before, and this particular day, while I did so, she told me about a bad experience she had as a child when a nurse started her IV. As before, her body language was the picture of calm while she talked. I inserted the IV easily. As soon as the patient saw the blood flash, confirming the IV was in the vein, she passed out, just like that. I yelled for help, but by the time my coworkers arrived, she was already coming to. With the innocent expression of a child she looked up into my face, and said, “Oh, it’s you.”

I disappointed myself. Her words had not matched her body language, and I missed it. I didn’t know how much courage it took for her to come in for treatment. I gave her some juice, and a little time to herself. When it was clear that her inner child had safely returned to her soul’s play room, I told her I was sorry. She apologized for not telling me how she really felt. She didn’t want to be a difficult patient. We talked about her fear of needles, and came up with a plan. She decided to finish her IV treatment, and I learned one more thing I already knew.