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Nursing Protocol for Telephonic Supervision of Clients
Access to care, client vulnerabilities, technology, and health costs affect not only the delivery of health care but also the roles, responsibilities, and opportunities for nurses. Patients are often managed in the home or discharged from hospitals before they or their families are ready. To address some of these needs, nurses are utilizing telehealth opportunities. For many nurses, telehealth translates to telephonic nursing. This article provides an algorithm that nurses can utilize in order to safely monitor patients in their homes. This can be a cost-effective program, particularly for those who are homebound or for persons, such as the elderly or those with chronic illness, who have long-term needs that vary between relative health and acute illness. This algorithm serves as a guide in our nursing practice for the telephonic supervision of patients in the home environment.
Telehealth is defined as the “use of communications technologies to provide support health care at a distance” (National Center for Nursing Research [NCNR], 1993). Nursing has been in the forefront of telehealth approaches to clinical care. Because using the telephone is convenient, inexpensive, and an alternative method of delivering interventions, it is especially important when a patient’s transportation is limited. “Telehealth approaches related to nursing care have the potential to serve a wide range of populations and to make a significant contribution to the nature and delivery of health care, improve access to healthcare practitioners and improve cost efficacy of interventions (NINR, 2000).
This algorithm to provide telephonic supervision of patients in the home environment has been utilized in our nursing practice. It has been helpful not only in describing what steps we are taking to assess patients but also in teaching other healthcare personnel to successfully monitor patients in their homes.
Nurse case management has successfully been utilized for patients who have chronic disease states (e.g., arthritis, heart failure, hypertension, hyperlipidemia, asthma), those who are seen as high risk, or those persons belonging to a vulnerable population (Allen et al., 2002; Barry, McQuade, & Livingstone, 1998; Dinelli & Higgins, 2002; Riegel et al., 2002). Patients may have associated illnesses or issues that must be taken into consideration in the management of their care. These case managers assist not only in monitoring patients’ health status but also their medications. In addition, the case managers provide education and support that often empowers the patient (i.e., self-efficacy). DeBusk, West, Miller, and Taylor (1999, p. 2741) state, “more effective treatment of patients with chronic diseases has the potential to decrease the need for treating acute and subacute episodes.” Therefore, there is also the potential for cost savings.
The aforementioned studies have examined the financial implications. Barry [arthritis] found length of stay decreased by 34% (1998). Riegel [heart failure] found hospitalization rates lower, as were multiple readmissions (2002). Costs were lower by 45.5% at 6 months for a difference of approximately $1,000 per patient over the 6 months of the study. Dinelli’s study [asthma] at 6 months found resource savings of $491.90 per patient.
Insurance companies are utilizing and expanding their disease management programs. They are encouraging their subscribers to take advantage of this service. Subscribers are then assigned a nurse case manager (CareFirst BlueCross/BlueShield, 2004; Clark, 2004). According to U.S. News and World Report (p. 44), disease management “offered by more than half of all employers and almost every major private insurer…is now a $750 million industry.” The report also states that in the first year Minnesota Blue Cross/Blue Shield started the disease management program “the program saved $36 million in medical costs” (p. 46).
Much of the monitoring has utilized the telephone (i.e., telephonic nursing and or telehealth). Studies have shown that skilled nurses can safely and effectively monitor patients in their homes (Martin, Coyle, Warden, & Salazar, 2003; McFarlane et al., 2004; Riegel et al., 2002). Riegel et al. studied patients with chronic heart failure and telephone interventions. Heart failure hospitalizations/readmissions, costs, and patient satisfaction with care were higher in the intervention group. Their primary aim “was to assess the effectiveness of a standardized telephonic nurse case management intervention in decreasing resource use…Each patient was estimated to require approximately 16 hr of a case manager’s time over the 6-month period” (i.e., an average of 17 calls; p. 706).
Martin et al. (2003) report on telephonic nursing effectiveness during a home program of rehabilitation with a military active duty population who had had a moderate to severe traumatic head injury. Patients were monitored by skilled master’s prepared psychiatric nurses over an 8-week period. The other arm of the study received 8 weeks of inpatient rehabilitation. Weekly phone calls averaged 30 min.
McFarlane et al. (2004) studied the effects of telephone interventions for victims of intimate-partner violence. Nurses made 6 (9 min) telephone calls over 8 weeks discussing safety-promoting behaviors. Follow-up calls at 3, 6, 12, and 18 months were made to assess safety-promoting behaviors. The study showed that at each assessment the intervention group practiced significantly more safety-promoting behaviors than the control group.
Nurses can evaluate adherence to prescribed medical regimens, provide and reinforce preventative healthcare practices, and promote education. If patients can experience greater satisfaction in their care, they may also experience empowerment over their health status.
Shaw, Feuerstein, Haufler, Berkowits, and Lopez (2001) examined military occupations identified as high risk for low-back pain. The study stressed the importance of “cognitive processes that may impact on coping ability and reduce pain and psychological distress” (p. 129). There exists a need to help patients learn problem solving and to reduce risk of future injury. This is the concept of self-efficacy—a problem they can overcome.
Self-efficacy (Bandura, 1997) is the belief about what one can do under different sets of circumstances with the skills processed. Personal efficacy predicts the goals one sets and the performance level in attaining those goals. People who are verbally persuaded that they possess the capabilities to master given tasks during difficulties are more likely to put forth and sustain greater effort than if they either dwell on personal deficiencies or harbor self-doubt.
Lackner, Carosella, and Feuerstein (1996) found perceived efficacy was predictive of physical functioning. If one had a sense of self-efficacy, the ability to withstand or alleviate pain affected the ability to endure it. This, in turn, influenced the use of pain and sleep medications. The belief that one can have some control over pain and physical functioning was accompanied by fewer pain behaviors, less mood disturbances, better psychological sense of well-being, and more active involvement with everyday activities.
Phone calls by nurses can monitor patients’ pain, their progress in therapies (particularly those done in the home), their ability to function at home and at work (when applicable), and their gradual return to optimal functioning. Nurses can assess medication compliance and efficacy. Nurses also assess psychosocial adjustment. Appropriate referrals to behavioral health or other services can be made if levels of anxiety or depression are noted to interfere with healthy adjustment.
Nursing Protocol and Algorithm Description
Figure 1 shows the steps in the protocol. The initial step is the development of a therapeutic relationship. The nurse-patient relationship is an interpersonal process that develops over time. This was conceptualized by Hildegard Peplau (1952). Peplau believed that this relationship, critical to care delivery, influenced patient outcomes. After this pivotal relationship has begun the nurse asks standard questions in order to assess and promote current safety, health, and recovery from the neurobehavioral event. The nurse and client determine perceived social support and the effect of stressors along with the level of functioning. This leads toward mutually agreed upon outcomes among the client, family, and treatment team. Activation of social supports and strategies to deal with stressors may be initiated by any or all of the three parties.
Should a patient deny any symptomatology, the nurse continues to support coping and healthy behavior by identifying independent behaviors that lead toward a gradual return to preinjury activities. This can be achieved, for instance, by psychoeducational and problem-solving interventions. The nurse facilitates and monitors adjustment to self, family, and community expectations until the outcome criteria that were previously set are met.
When there is an acknowledgment that medical or psychiatric events need monitoring or nursing intervention, the nurse assesses the degree to which these symptoms interfere with daily functioning/self-care/and social interaction. If the symptoms do not interfere, the nurse will continue to monitor and offer support, education, and feedback until the outcome criteria are met. If the symptoms are interfering, the intensity and spectrum of the symptoms are assessed in order to determine appropriate means of alleviating them. To include the medical point of contact, it should be noted that the nurse will be collaborating with other team members as needed to keep the team informed and offer a multidisciplinary and holistic team approach to care.
As shown in Figure 1, the nurse can use five pathways to address symptom management. Any or all of these pathways may be activated. This system provides a network so nurses may employ alternate means of achieving the set goals. These pathways are fluid and act as a guide to allow for flexibility and creativity. Achieving the outcome criteria that were set is the ultimate goal.
Pathway 1: Psychoeducational Intervention
Nurses should work with the patient—and significant others, if needed—to assess their means of identifying and acknowledging concerns in order to solve problems. The nurse may need to develop strategies for addressing interpersonal problems. She or he also provides and reinforces educational information on medical or emotional issues. Nurses may need to provide access to further informational resources as well. Role-playing with the patient, approaching difficult issues in a nonjudgmental way, and offering support and feedback are interventions nurses may utilize. Patients and significant others often learn differently—by visual, auditory, or tactile (i.e., by doing) means. A variety of educational materials are either available or can be produced (i.e., videos or pamphlets).
Pathway 2: Alternative Means of Relaxation Techniques
Nurses should decrease the anxiety level so that healthy adjustment may occur. This pathway also incorporates educational interventions, because the nurse may need to either teach the patient or find the resources for the patient to learn various stress-reduction techniques. Complementary services (e.g., massage, aromatherapy, and visualization) may be offered. Journaling to identify concerns can be an effective tool both on a cognitive and emotional level. By sharing journal entries with the nurse or significant others, the patient uses cognitive skills. Writing allows patients to vent emotions and voice concerns in a nonthreatening manner.
Pathway 3: Environmental Intervention
The nurse need not make a home visit to be able to assess the patient’s home environment. Safety issues within the home environment encompass not only the physical structure of the home (e.g., steps to climb/lighting/ bathroom access) but also potential caregivers of physical and emotional support. Neighbors can be enlisted to check in, and visiting nurses, community supports (e.g., Meals on Wheels), and extended family and friends can be identified.
Patients may need assistance in identifying stressors within their environment. For instance, if music or the television is played too loudly by others, identifying a quieter room for the patient or taking a short walk may be suggested interventions. The patient or other family members may be able to use public libraries, community centers, and public transportation.
The work environment may be able to accommodate patient needs, including the physical relocation of an office (i.e., move it closer to a bathroom, situated with no stairs to climb), ergonomics (e.g., chairs and work stations), access to a refrigerator (i.e., if medications need refrigeration). An organization may offer flexible work hours or telecommuting days if asked.
Pathway 4: Medication Adjustment or New Intervention
Nurses assess effectiveness of current medications and compliance. Is there a need for adjustment to the current regimen or are new medications warranted? Nurses should query prescription medications, over-the-counter drugs, and herbal or supplementary medications. The nurse’s assessment may indicate the need to contact the medical provider to adjust medications.
Pathway 5: Medical Conditions Warranting Referral
Set clear guidelines and parameters for when a patient needs to have treatment at a clinic or hospital (obviously, if there is a danger to self or others). Depending on the medical condition of the patient, what is considered a medical emergency may need clarification. Written guidelines could be helpful for patients and families (e.g., “If you experience the symptoms listed, call immediately.”).
All pathways will lead toward the assessment of frequency in monitoring the patient via telephone, mental status, and daily functioning. Again, the nurse will support coping and healthy behaviors by identifying independent behaviors leading to the gradual return to preinjury activities. The nurse also facilitates and monitors the adjustment to self, family, and community expectations. After outcome criteria have been met, the nurse-patient relationship may be terminated.
This article provides an algorithm, or nursing protocol, for nurses to use during telephonic supervision of patients. This algorithm is a fluid system in which the nurse—with the input and feedback from the patient—continuously reassesses progress and needs. The feedback loop is constant. Telephonic intervention by nurses, after a therapeutic relationship has developed, cans provide consistency during a chronic illness or through the rehabilitation process of an acute event. These interventions also allow patients to develop a sense of mastery over their situation. Using self-efficacy via telephonic nursing teaches a useful theory in helping clients change, reinforces health behaviors, and moves patients toward optimal functioning.
The opinions and assertions contained in this article are the authors and do not necessarily reflect the views of the Department of the Army, the Department of Defense, or the Department of Veterans Affairs.
About the Authors
Elisabeth Moy Martin, RNC MA, is a research nurse for the Defense and Veterans Brain Injury Center, Henry M. Jackson Foundation, Washington, DC. Direct correspondence to her at 6709 Tomlinson Terrace, Cabin John, MD 20818 or email@example.com.
Mary Kathleen Coyle, MS APRN BC, is an associate professor at Prince George Community College School of Nursing in Largo, MD, and a doctoral candidate at The Catholic University of America, Washington, DC, School of Nursing.
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