Telenursing is a care delivery method that has been used for decades. Recent studies, however, focus more on the tools used when providing client care and the potential use of telehealth technology to conduct tele-clinical trials or to measure the satisfaction clients have for receiving telephonic health care. The most recent studies have been conducted in New Zealand, Great Britain, and Greenland. One article, though, was a systematic literature review that identified four basic themes in the literature about telenursing: impact on client satisfaction; impact of comorbidities and participation in telenursing care; use of telenursing as a form of intensive care; and training. Of these four themes, the one that has been least studied is the impact of telenursing on nursing education.
Telenursing is expanding throughout the United States. Nurses conduct care “over the telephone” to complete assessments, evaluate medical treatments, and follow-up after hospitalizations. It is a very real and positive approach to client care.
Nurses who provide telephonic care can be employed by health insurance companies, health care systems, and disease management organizations. Nurses who fill these roles have experience in direct client care but may lack comfort in providing care when unable to “see” and “touch” the client. Clients who are enrolled in telenursing programs demonstrate skepticism regarding the purpose and intention of being contacted by a nurse to “talk about” their health.
Although the science behind telenursing is obvious, it is the “art” of telenursing that makes it unique. This approach relies on one of the most basic skills in which we all engage from an early age–communication. Yet the use of this skill can be intimidating to new telephonic nurses.
Telephonic nursing is slowly being introduced into schools of nursing curricula. Reasons for this may include access to call centers with telephonic nurses. The Veteran’s Administration has been identified as one site for students to observe telephonic client care. For telephonic nursing care to be fully embraced, schools of nursing need to identify locations and opportunities for students to observe, learn, and participate in this approach to care delivery.
The foundation of nursing is built on establishing relationships. Therapeutic relationships are those that help facilitate an improvement in health, compliance with prescribed medical regimens, and empower clients to implement actions to improve their own health situations. There is no one better than a telephonic nurse to model and teach the creation and implementation of therapeutic communication.
Unfortunately, there has not been anything written to help teach the nurse how to perform telephonic nursing skills… until now. If you are considering a telephonic nursing care position, then Telehealth Nursing: Tools and Strategies for Optimal Patient Care is for you. If you are a student who is challenged by talking with assigned clients, this text is for you. And, if you are a nurse who is searching for another way to practice your craft, this text is for you.
For those who doubt the value of this care approach, studies that focus on the effectiveness and outcomes are encouraged. Telephonic nursing practice is guided by the 2011 Scope and Standards of Practice for Professional Telehealth Nursing, published by the American Academy of Ambulatory Nursing. Telephonic nursing care is here to stay and will only get better with focused attention and study into the processes and approaches that make it one of the most current and cost-effective methods for client care and teaching.
As an emergency room nurse, there are several times per day when I am presented with an opportunity to provide patient education. From dispelling common myths in triage to providing discharge instructions, it is one of our most important roles as nurses to provide solid education to the patients and families we meet every day.
Whether it’s the importance of hand hygiene, or how to properly take antibiotics, or the home management of diabetes, every piece of information we can impart to a patient can make a real difference in the wellness and health maintenance of our patient population and their families. Providing patient education is just as important as the other nursing care we deliver.
In a perfect world, nurses would have unlimited time to sit with patients and make sure they’re hearing what we are saying. We would have time to assess their preferred learning methods and to help them understand. We would have time to do a 15-minute crutches demonstration, for example, or to go over every possible side effect. And some days, we can! But how can you make sure you’re not skimping on patient education when staffing is tough, you’re stretched too thin, and when patient education might otherwise fall by the wayside?
Write it out. Sometimes I don’t have the time I would like to fully explain a patient’s home care instructions, but boy am I a fast typer (thanks, electronic medical records!). It takes me only a few moments to quickly type out home care instructions. Then, anything I want them to remember I know they are at least taking home with them. This is essential, since they won’t necessarily remember exactly what I said, but can refer back later to what I wrote.
Print! Find a patient education material app or website that you like or that your facility participates with. For me, it’s Mosby or Up-to-Date, which has pages and pages of patient information and handouts designed specifically for printing and passing over to the patient. Most are written at an easy reading level and include illustrations, and many are printable in other languages, as well.
Highlight! Stick a highlighter in one of your (overflowing) scrub pockets. If you’re pressed for time, highlight the most important pieces of the discharge paperwork for easy review. There is a lot of great information in a discharge packet, but there’s also a lot of extras. Make sure to give a brief guided tour of the paperwork and point out relevant lab results, follow up instructions, and home care.
Use teach back. One of the best ways to ensure patient learning is to ask them to teach it back to you, or at least repeat it back. You would be surprised how many times you have just gone over something only to have the patient forget what you just said or have missed your point entirely! It’s worth taking a moment to say, “Now tell me, what signs and symptoms would prompt you to seek help?”
Keep it brief. Remember, most people can only remember one or two learning points. Try to pick the most important ones to emphasize with the patient, and leave the rest for the (highlighted!) paperwork.
Include family members. If an elderly person seems particularly adverse to learning about fall prevention, enlist any family members to help. Especially in the case of family caregivers, who play a crucial role in patient’s well-being at home, it’s important to involve them in the learning process.
Don’t assume that your patients already know what you’re going to say. Don’t assume that the diabetic or hypertensive patient knows to take their medications even when they’re ill. Don’t assume that parents know to give their children the appropriate dosages of medications based on the child’s weight. Don’t assume that someone with a GI bug knows to eat a BRAT diet when resuming foods and fluid intake. Say it anyway!
Allow enough time for questions. Give the patient ample time to ask any questions about follow up care, medication side effects, or any disease process or health maintenance after discharge. Make sure he or she knows who to follow up with, too. I usually phrase this as “Ask me anything right now, and direct all questions after you leave to Dr. Smith or your primary care physician.”
Don’t leave it all for discharge! Remember to provide bits of information and patient education throughout your care for a patient and not just at the end of his or her visit. This prevents overwhelming the patient with details as they are about to leave, and helps make sure more of what you say can be retained.
It is our responsibility to ensure health literacy and competency in our patients, and that can start with little bits of information and education that we can pass along all throughout our care.
Remember when you were so excited to start your job as a nurse? However, as the years tick by, it’s not uncommon to lose some of your joy and enthusiasm. You may find yourself stuck in a routine or cruising on autopilot; you do your job, then you leave, and you repeat this pattern the next day. The good news is that the delight you once felt for your job doesn’t have to be lost forever. Here are four ways to find joy in your job again.
1. Develop a support system.
Create a circle of coworkers who have similar life interests and values as you do. Knowing you have a supportive network of nurses and other health professionals to rely on eases stress and gives you a friendly environment to share your feelings. Job pressures tend to decrease when you surround yourself with people you consider friends. Don’t have any friends at work? Sometimes you have to make the first move to get to know your coworkers.
2. Learn a new skill.
It’s frustrating to feel like you don’t have the right tools in the toolbox to help the variety of patients you see every day. Use this frustration as an opportunity to grow as a nurse and seek additional training in your areas of weakness (to build your confidence) or interests–whatever sparks your professional passions. Ultimately, you’ll find your job becomes a lot more engaging when you stretch your professional comfort zone to include new skills.
3. Ask for help.
Your attitude as a caregiver is critical to your patient’s health care. But it can be hard to maintain a positive attitude when you’re feeling overworked and overwhelmed. If you find yourself in a negative head space more often than not, maybe you need to ask for help from a fellow nurse, the office staff, or your manager. If you need something changed to have a happier work environment, be bold enough to ask for it. It’s possible you’ll get what you want and rekindle the joy of your job in the process.
4. Learn to let go.
Nursing involves a great deal of emotional labor–or the process of regulating feelings and expressions to fulfill the requirements of your job. If you’re seeing a patient within the context of a health facility, then you already know you’re not seeing them at the best time in their lives. Unfortunately, you might be on the receiving end of someone’s battle with pain, illness, or injury, and chances are it’s challenging at times (to say the least). By realizing a patient’s struggle isn’t a personal attack on you, you’re better able to “let it go,” shrug it off, and focus on the most rewarding parts of your day. It’s easier to feel joyful about your job each day when you focus on the good you’ve done for your patients.
Below, I interview Erin Sullivan, BSN, RN, CEN, about her experiences in critical care. She recently switched her specialty from the emergency nursing to intensive care, and shares her reflections, challenges, and some advice.
What is your background in nursing?
I graduated as a second degree nursing student from George Washington University in 2014. I was a new graduate nurse in the emergency department (ED) for about two years before I switched to the MICU (medical intensive care unit) in March 2016.
When did you decide to change specialty, and why?
I decided to switch to the ICU about 18 months into working in the ED. At the time, I was considering applying to some graduate school programs that required ICU experience as a prerequisite, so I made the switch to broaden my experience and learn a new skill set.
What do you do now and what is your job/where?
I’m working in the MICU at Northwestern Memorial Hospital in Chicago. I also still work per diem in an ED.
What was challenging about the transition to the ICU?
The biggest challenge I had in transitioning from emergency nursing to the ICU was learning how to think like an ICU nurse. There are jokes in nursing that the two types of nurses are “wired differently.” In the ED, the goal is to quickly assess, diagnose, and stabilize patients, and then to move them out to an appropriate level of care as soon as possible. In the ICU, the goals for the patient are more long term, and you have to consider a bigger picture and a larger scope than I would in the ED. It’s a completely different way of thinking, organizing, and prioritizing patient care.
What do you miss most from ER nursing?
The thing I miss most about the ED is the teamwork. I don’t know that I can quite explain the team aspect of ER nursing to someone who’s never experienced it, but there is a special camaraderie that forms between all of your coworkers. Whether it’s one of the best shifts or the worst shift ever, your fellow coworkers join together to make sure we all come out on the other side. I also miss the organized chaos that is the ED, and the anticipation of never knowing what is coming through the door next.
What do you enjoy most about the ICU?
Being in the ICU, I really enjoy being able to watch a patient progress from being critically ill to becoming well enough to leave the unit. Unlike the ED, many times you have a patient three or four shifts in a row, so you can get to know the patients in a way I never got to in the ED.
What do you want to do with your nursing career moving forward?
I’m not sure what the next step is in my career. One of the reasons I chose nursing was because there are so many different options in what you can do. For now, I’m enjoying working in the MICU and picking up in the ED every now and again to get my adrenaline fix. I’m fairly certain though that I’ll find myself back in school pursuing a graduate degree in nursing at some point.
What tips or advice do you have for someone who wants to change their specialty?
My biggest advice for anyone considering switching their specialty is just to do it. As nurses we learn new things everyday, and we shouldn’t be intimidated or scared of the challenges that come with switching specialties!
That said, do your research. Can you handle the stress of a new job right now? Are you adaptable and a quick learner? Do you get along well with new people? These are all considerations before jumping into a new specialty. For me, I was still within the broader scope of critical care. If you’re completely changing specialties, from adults to pediatrics, or from med-surg to labor and delivery, make sure you talk to people who are in that field and that it seems like the right fit for you. But remember, you can always go back!
Working on a holiday can be tough, but there are ways to make it not only tolerable, but fun. We asked some nurses who work on the holidays for tips on how to make the time special and enjoyable. Here’s what they had to say:
“Sometimes, involving patients can be fun, too. I worked night shift with other men a few years ago, and when the Cavs got deep into the NBA playoffs, we had parties in the rooms of conscious patients who enjoyed basketball. The same can be done with Christmas movies, the Super Bowl, etc. and benefits everyone.
Decorating the unit and potlucks are a must, but again, involve patients and their families—especially on floors where patients stay long term—really helps everyone have more of a home outside of home.”
—Nick Angelis, CRNA, MSN
“One thing we do to keep it fun and festive [in the NICU] is to take sweet holiday photos of the babies in giant red stockings, so the parents have a cute keepsake from their baby’s first Christmas.
We always have a delicious potluck so that all of us—nurses, therapists, doctors—have wonderful, home-cooked food to look forward to on our long 12-hour shift.
Holiday-themed scrubs, Santa hats, paper snowflakes decorating the walls, and Christmas music will all bring cheer to families visiting their babies in the NICU.
If you’re allowed to decorate the walls, it’s cheap and easy to cut paper snowflakes and brighten the mood everywhere—the front desk, the patient rooms, anywhere it will bring cheer. And it’s something you can do last minute if there’s nothing else around your unit that is cheerful.
If your hospital allows you to choose your own scrubs, you can find cute holiday-themed scrubs, or just decorate your green or red scrubs with a holiday pin, a Santa hat, or a red and green lanyard for your ID.
If you’re working the night shift, consider bringing in Christmas lights, miniature Christmas trees with lights, or even plain fairy lights to string from the monitors and IV poles to make the mood more festive.
It really does feel good to give on the holidays, so consider writing some sweet “Happy Holidays” note cards ahead of time that you can give out to your patients that day.
We have volunteers who bring in their therapy dogs to visit patients, and on Christmas they have the dogs dressed in holiday sweaters and Santa hats, delivering small gifts to patients like Santa.
These are a couple things we are not doing but I think it would be awesome:
Performing a holiday flash mob—breaking into Christmas song and dance to bring a smile to our patients.
Have a group of carolers stroll through the halls, singing acapella Christmas carols to all of the patients who wish to feel festive.”
—Trish Ringley, RN, and owner of www.EVERYtinyTHING.com
“As nurses, it is our role to administer medications on an as-needed basis, or ‘PRN.’ This includes reliefs for pain, nausea, anxiety, etc. Alongside performing hourly rounding on our patients, we offer these PRN medications aiming to keep the patient as comfortable as possible. For every PRN medication that a nurse administers, they receive candy canes. Whoever collects the most candy canes by the end of a 12-hour shift receives a gift card to any restaurant near the facility or a free meal provided by the hospital cafe. This game makes working on Christmas fun and engaging, and it also provides an opportunity for nurses to go above and beyond and assure that their patients will have the best holiday possible while being cared for.”
—Shawn Butler, LVN
I was recently asked by a colleague who was preparing a presentation about ethical issues in pediatrics to share with him my thoughts about this topic, in light of my experience as a pediatric nurse. My recounting grew into an essay about the joys and challenges of caring for children and their families at some of the most vulnerable moments of their lives.
Easy to Forget
There’s something I said regularly during my years at the bedside. I remember saying it one night when a neurosurgeon and I were using a syringe and scalp vein needle to draw 30 milliliters of crankcase oil-colored spinal fluid from the brain of a tiny baby. I said, “You know, it’s easy to forget that not everybody’s job involves doing stuff like this.” I heard that sentiment many times from the other side as well: I worked in a NICU at a regional referral hospital, and grandparents would come from outstate to visit their newly born, seriously fragile grandchildren. They would say, “We never knew there was a place like this. And we wish we didn’t know.”
In order to continue to function in the profession we have chosen, we have to become accustomed, inured, some might say desensitized, to regularly doing extreme things, including things that cause pain to the people we are trying to help. There’s a subset of caregivers, especially if they don’t have other, unrelated but strong, influences and activities in their lives outside of work, who lose track of this discrepancy, to the point where they aren’t able to articulate the extremity of what we do – it’s like asking a fish about water. But in the NICU where I worked for 25 years, one of the reasons why we survived and why I loved so many of my coworkers is because they had lives outside of work – families (we helped each other raise our children), crafts (many knitters, scrapbookers, quilters, all giving each other ideas), culture (many musicians, theatergoers, movie fans), and literature (we had a lending library and an informal book club during breaks). They were whole, broad people, with a particular skill that society finds useful but takes a great personal toll.
A Family Affair
Since pediatric patients (except for some older teenagers) can’t act independently, pediatric health care is by necessity a family affair. So another aspect of peds is that the emphasis on the family often gets extended to staffs and caregivers as well. Staffs on pediatric units and in clinics are more likely than on adult units to be seen through the metaphor of a family (sometimes overtly in the cultural language of the unit, sometimes covertly by leaders who try to re-create the nuclear family among their staff). This can lead to all kinds of problems with boundary issues, stress for staff members for whom family is a negative or even traumatic construct, and extra mental work for people who are just trying to manage their intra- and interdisciplinary roles, let alone sibling rivalry and funny uncles.
When Errors Happen in Pediatrics (or, When Bad Things Happen to Helpless People)
Errors, especially those that reach the patient, and most especially those that cause demonstrable harm, are traumatic for everyone whenever they occur. But in pediatrics, errors are especially devastating because most pediatric patients can’t speak for themselves, and their families are left with the added burden of feeling that they failed in their duty to protect their children from harm.
The “brand” of pediatric health care is full of very visual stories about miracles – tiny premature babies with tubes and wires all over their bodies who survive against all odds; bald kids with cancer who grow up to be physics majors; toddlers missing a limb who are learning to walk with prosthetic legs. The reality is that errors of commission and omission occur in pediatric health care, but the backdrop of the narrative of miracles makes the errors that do happen more salient and less understandable and forgivable – it’s regarded by some as if the person who made the error is ignoring God’s will, or even working against God’s will.
Pediatric Weight Differentials – Source of Error
In adult medicine it’s possible for one patient to weigh twice as much as another. But in a pediatric unit, it’s not unlikely for a nurse to have two patients assigned to her or him, one weighing 4 pounds (e.g., a post-op premie or a newborn with failure to thrive) and one weighing 400 pounds (e.g., a morbidly obese teenager with asthma). When you have weight differentials this wide, the potential for overdosing, underdosing, and errors in prescribing, dispensing, and administering medications is huge. Computerized medication management systems help minimize the chance of error, but the overarching issue remains.
There’s a useful teaching question for health care professions students: What is the correct dose of most medications? The answer is: one. One tablet, one capsule, one teaspoon, one milliliter, one suppository, one spray. Drug companies create their products this way, for ease of use and for safety, and for full-size human beings, it works quite well. However, in pediatrics, all bets are off.
Patient-Controlled Analgesia in Pediatrics
This topic is symbolic of the unique world of peds. When hospitalized grownups have pain, they may be provided with IV pumps that let them, within pre-programmed safe parameters, give themselves bumps of pain medication. Pediatric patients younger than about 15 can’t reliably manage this process themselves. But since the pre-programmed pumps are a safer, easier, and more sterile way to manage pain using IV meds, many pediatric patients, including infants in NICUs, now have the pumps, with the boluses of medications given by nurses, often as an adjunct to continuous infusions of those same medications. There are errors associated with these pumps, so that they may be seen as less safe than the former, intermittent, one-shot-at-a-time process, but actually the errors are fewer now, and overmedication is no more frequent. This pump technology is still resisted by some pediatric health care professionals.
Just Say No: Preventing Narcotic Addiction in Small Children
When I started my career in pediatrics in 1967, the received wisdom was that the few premature babies that survived did not experience pain. It wasn’t unusual for a baby to have major thoracic or abdominal surgery and receive no post-op pain medication at all. We thought we were saving lives, because pain medications cause hypotension. In the rest of pediatrics, the word was that, since toddlers and young children snapped back from surgeries and fractures more quickly than grownups (which was observably true), they didn’t need pain medication for such a brief span of time. For teenagers, our goal was to keep these kids from learning that taking drugs can feel good. The overarching goal was to prevent drug addiction, and if the patients had uncontrolled pain, the trade-off was worth it.
We have come a long way since then, but those attitudes and values remain, especially in some health care professionals of my generation.
Reluctance to Refer to Pain Management and Palliative Care Services
In many in-patient settings, including pediatrics, the people (especially the physicians) who are the experts in pain management are the same people who are experts in hospice and palliative care. They also tend to be people who are open to Complementary and Alternative therapies. They may dress differently than mainstream physicians and their body language and proxemics are often different than mainstream physicians. Their offices may be in the basement of the hospital or even off-site. They may well be the only physicians who attend presentations about caregiver self-care, even though they are the ones who may need it the least. And physicians who are allergic to hospice and palliative care for children, seeing it as admitting failure, may view a referral to the Pain and Palliative Care Service as a referral to a service that is a cultural outlier: not scientific, not medical, not one of us. The patients and their families, as well as the nurses who are caring for these children with poorly controlled pain, all suffer from this reluctance to refer.
End-of-Life Care for Pediatric Patients
Decisions about withholding or withdrawing treatment are very different for a premature baby, a toddler with end-stage cancer, or an adolescent who is in a vegetative state after a brain injury, than they are for a 90-year-old person, especially a 90-year-old person with an advance health care directive. But futile treatment is a reality in pediatrics, too. A frequent scenario involves a group of providers who have done everything they are trained to do and that their oath directs them to do, to save the life of a child. When the life is not saved, a pediatric death with dignity is not in their mental repertoire, but neither is a referral to experts in pediatric death with dignity. The ethical principles of beneficence, non-maleficence, efficacy, and justice, when applied to pediatrics, assume that the child’s parents are the ones best able to decide for and advocate for the child. But many times when treatment has become futile, the parents have no experience in these kinds of decisions and take their cues from the providers. The nurses are caught in the middle, continuing to perform painful, time-consuming, possibly expensive, clearly futile treatments. The term Moral Distress resonates with every nurse who has walked this path. And, going back to my initial comments about easy to forget, our families, friends, acquaintances, and the strangers we encounter in our daily lives, usually have absolutely no clue about this path we are walking.