Assessing the Obstetric/Gynecologic Patient by Telephone
Vicki E. Long
Assessment is a cornerstone of nursing practice. The ability to gather data in order to form an opinion about a patient’s situation and ultimately participate in formulating a plan of care is integral to all that nurses and other licensed providers are taught to do. However, assessing a patient by telephone presents some hurdles to an assessment, plan, implementation, and evaluation. The telephone, for all its convenience and immediacy, robs us of the opportunity to use many of our senses. It takes additional skill to overcome the innate deficit of the medium.
Imagine the familiar childhood poem, The Blind Men and the Elephant, by John Godfrey Saxe (1816-1887) (in Saxe, 2012). The poem relates the tale of six blind men who approach an elephant from different angles. The one who feels only the side of the bulky beast thinks the elephant is like a wall. The fellow who feels only the trunk equates the elephant to a snake, and the man who touches the tail is certain the elephant must be like a rope. In all, there are six different men with six different ideas of the essence of an elephant. Each is partially correct, but all of the men are wrong in their total view of the magnificent animal. That simple poem conveys the message that limited sensory input minimizes our perceptions and leads to misunderstanding. In the health care world, such limited perception can be very dangerous.
This chapter discusses some of the basics of telephone assessment. Experienced triage nurses and other licensed providers in obstetrics/gynecology (in this and other chapters, the term nurse is generally employed) find much of this redundant because these skills have become integrated into their daily practice. One of the difficulties of telephone triage is that a large body of research or a tradition of educational processes for these skills do not exist. Those in triage roles tend to be experienced nurses who have gained much knowledge over time but have worked with relatively little documentation. However, it is vital to assemble knowledge into a communicable form for the purposes of educating nurses and others in triage skills and validating what experienced triage providers already do on a day-to-day basis. To this end, this chapter begins by examining the evidence that assessment can be adequately and competently conducted through telephone contact with nurses.
» THE EVIDENCE FOR ASSESSMENT BY TELEPHONE
A review of relevant literature reveals that telephone assessment is currently being used in various specialties for a vast assortment of patient management issues. From assessing compliance in abnormal Pap smear follow-up (Miller et al., 2013) to evaluating
effectiveness of telephone-delivered depression management (Posmontier, Neugebauer, Stuart, Chittams, & Shaughnessy, 2016), the use of the telephone as an assessment and management tool is widely established. The use of telehealth can be found in specialties as diverse as gastroenterology, obstetrics, oncology, radiology, and rheumatology among many others (Chauhan et al., 2016; Desrochers, Donivan, Mehta, & Laizner, 2016; Miller et al., 2013; Posmontier et al., 2016; Rodger & Steele, 2008; Rutenberg & Greenberg, 2014; Salisbury, 2014; Zhang et al., 2017). Its use is documented in medical literature worldwide, from Australia to Turkey (Cottrell, Hill, O’Leary, Raymer, & Russell, 2017; Hintistan, Nural, Cilingir, & Gursoy, 2016).
effectiveness of telephone-delivered depression management (Posmontier, Neugebauer, Stuart, Chittams, & Shaughnessy, 2016), the use of the telephone as an assessment and management tool is widely established. The use of telehealth can be found in specialties as diverse as gastroenterology, obstetrics, oncology, radiology, and rheumatology among many others (Chauhan et al., 2016; Desrochers, Donivan, Mehta, & Laizner, 2016; Miller et al., 2013; Posmontier et al., 2016; Rodger & Steele, 2008; Rutenberg & Greenberg, 2014; Salisbury, 2014; Zhang et al., 2017). Its use is documented in medical literature worldwide, from Australia to Turkey (Cottrell, Hill, O’Leary, Raymer, & Russell, 2017; Hintistan, Nural, Cilingir, & Gursoy, 2016).
The real question is not just that it is widely used but that it has been found to be effective when properly developed and implemented by skilled health care professionals. There is ample documentation that qualified health care professionals are capable of transmitting therapeutic and useful information over the telephone. Hintistan et al. (2016) studied the therapeutic effects of nursing telephone communication with lung cancer patients in Turkey, concluding that telephone advice and support can reduce the effects of chemotherapy-induced symptoms. In a randomized controlled trial, Salisbury (2014) concluded that in patients with musculoskeletal complaints, telephone assessment and advice are equally effective to clinical care and can reduce cost when compared to face-to-face management. Even in the field of radiology, one of the most heavily litigious medical specialties, registered nurses are tasked with identifying and assessing high-risk patients via the telephone for postprocedural complications. Rutenberg and Greenberg (2014) point out that postprocedural problems compose the second most common classification of radiology lawsuits. Such nurses are definitely assigned an important and weighty task.
The perception of the care delivered via various communication modalities utilized in telephone triage has been evaluated by both patients and caregivers. Desrochers et al. (2016) used a qualitative descriptive design to explore Canadian cancer patients’ and their family members’ views of their assigned clinical nurse specialist’s delivery of psychosocial care during telephone triage assessment. These authors concluded that the nurses were able to individualize strategies for participants as needed, fostering the trust necessary to provide effective psychosocial support while performing ongoing, competent assessments. Zhang et al. (2017) undertook a meta-analysis to appraise the impact of telephone-led management on quality of life and prognostic outcomes for breast cancer patients and survivors. Fourteen randomly controlled trials, totalling over 2000 individual patients, were included (Zhang et al., 2017). Statistically significant positive effects were found with “anxiety, self-efficacy, social-domestic function and quality of life” (Zhang et al., 2017, para. 2). Although the authors concluded the data for depression, fatigue, and self-efficiency trended toward positive effects of those respective disorders, statistical significance was not established for those categories due to the small number of studies that were found.
Rutenberg and Greenberg (2014) point out that both the nurse and patient usually have an outcome in mind when engaged in a health-related telephone conversation.
However, proficient nurses know that their agenda may need to change based on the patient’s information. Even when using protocols and guidelines as described in this book, nurses’ must be attuned to the possibility of unanticipated complications and hidden problems. Telephone triage nurses of all levels of experience have pointed to the impact of personnel characteristics, quality of consultations available to them, and organizational issues in the work environment as having negative effects on the ability to concentrate on doing their jobs (Wahlberg, Cedersund, & Wredling, 2003). Wheeler, Greenberg, Mahlmeister, and Wolfe (2015) looked closely at patient safety by classification of caregiver. They evaluated studies published over a 10-year period, from 2002 to 2012. “Safety” was defined as appropriate referrals, which included identifying the appropriate place, time, and person(s) involved in assuring the desired outcome for the patient. Safety was further described as also including the essential components of “guidelines, documentation, training and standards” (Wheeler et al., 2015, para. 1). Nurses were consistently rated more competent than physicians, and telephone triage was found to be least safe when the individual responsible for the advice given worked within a system that was seen as lacking in those aforementioned essential components.
However, proficient nurses know that their agenda may need to change based on the patient’s information. Even when using protocols and guidelines as described in this book, nurses’ must be attuned to the possibility of unanticipated complications and hidden problems. Telephone triage nurses of all levels of experience have pointed to the impact of personnel characteristics, quality of consultations available to them, and organizational issues in the work environment as having negative effects on the ability to concentrate on doing their jobs (Wahlberg, Cedersund, & Wredling, 2003). Wheeler, Greenberg, Mahlmeister, and Wolfe (2015) looked closely at patient safety by classification of caregiver. They evaluated studies published over a 10-year period, from 2002 to 2012. “Safety” was defined as appropriate referrals, which included identifying the appropriate place, time, and person(s) involved in assuring the desired outcome for the patient. Safety was further described as also including the essential components of “guidelines, documentation, training and standards” (Wheeler et al., 2015, para. 1). Nurses were consistently rated more competent than physicians, and telephone triage was found to be least safe when the individual responsible for the advice given worked within a system that was seen as lacking in those aforementioned essential components.
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