Mastering Telephone Communication Skills Workshop Series

Teaching Telephone

Communication Skills

 September 2015

John Kedward

Associate Dean, HEEoE

Your learning needs?

What to consider when planning

teaching of telephone comms skills

•

Type of learner(s)

•

Learning needs of the learner(s)

•

Expertise of the teacher

•

Resources you may need

•

Number of learners – 1:1 or group

•

Context of telephone assessment

•

Why is it a separate skill?

•

How are changes in service delivery

affecting telephone competencies?

Group work

•

In groups of three consider different

ways of teaching telephone consultation

skills

•

Identify a learner group

•

Plan a workshop session

•

Consider pros and cons of each method

used

•

What resources would help you?

Modules to consider

•

The methods used to teach will depend

on the number of trainees and the time

available.

•

One day can cover a lot

•

Half a day can cover most

•

Less likely to achieve much with one hour

session, unless repeated

MODULE ONE: INTRODUCTION

•

Key objectives

–

Understand what is different about telephone

consultations and the implications of this.

–

Provide a structure and a model for learners

to use to ensure key tasks completed.

repeated. Structure/ models -telephone

assessment

•

Methods

–

Presentation plus group work with plenary

feedback

•

Duration

–

One hour

MODULE TWO: ASSESSMENT

TOOLS

•

Key objectives:

–

To understand how to assess the quality of different

aspects of telephone consultations

–

To practice using the tools with benchmarked audio

recorded telephone consultations

–

Benchmark and compare scores in small and large

groups, understand why score differently and reflect on

what that means about own gaps.

•

Methods

–

Presentation and explanation of one or more tools –

how to score, what scores mean?

–

Listen and score some good, average less good calls

–

Plenary benchmarking and comparing scores

•

Duration

–

90 minutes or more

MODULE THREE: ROLE PLAYS

•

Key objectives

–

To practice doing telephone consultations in a

supported way with scenarios, where your role plays are

objectively assessed and you are given developmental

feedback

•

Methods

–

Option of using professional role players/ learner role

players, use an additional observer

–

Rotate role and practice several role plays

–

Small group feedback

–

Large group plenary

•

Duration

–

60 minutes or more

MODULE FOUR: TOP TIPS &

ADVANCED SKILLS

•

Key objectives:

–

To learn what works well and where the pitfalls

are from experience of others, from significant

events, etc

•

Methods

–

Presentation & group discussion

–

Significant event presentation, or audio file

–

Group discussion of lessons learned

–

Role playing different approaches to challenging

scenarios

•

Duration

–

One hour or more

MODULE FIVE: ONLINE VIRTUAL

PATIENT SCENARIOS

•

Need permission and login

•

Pilot Project HESW

•

Seven modules different login for trainer

and trainee

•

Focussed on different aspect of

emergency care and OOH care

•

Supports curriculum assessment in

emergency care and OOH care

•

http://uchoose.uwe.ac.uk/Player/Play

•

Suitable for 1:1 and self-directed learning

Discussion

Options for rest of session

•

Listen to call and score it.

•

Do a role play

Have we addressed your learning

needs?

Telephone consulting is…

•

“

t

h

e

m

o

s

t

d

i

f

f

i

c

u

l

t

a

n

d

c

h

a

l

l

e

n

g

i

n

g

a

s

p

e

c

t

o

f

G

e

n

e

r

a

l

P

r

a

c

t

i

c

e

.

I

w

o

r

k

h

a

r

d

t

o

g

e

t

i

t

r

i

g

h

t

a

n

d

d

o

i

t

w

e

l

l

.

”

(GP of 20+ years experience and a

trainer)

Differences between telephone

and face-to-face consultations

- FLIPCHART

•

Opportunity to examine

•

Body language / physical pointers

•

Easier to communicate when have all other

aspects (visual contact etc.)

•

Harder to avoid the problem

•

Easier to establish rapport & empathy

•

Can observe other aspects (social / family)

•

? Encourages dependence on face to face

contacts whereas advice may encourage self-

reliance

•

History only

•

No previous relationship

•

No knowledge of PMH

•

Not necessarily talking to patient

•

More difficult to establish rapport

•

Easier to put people off

•

Easier to push dr's agenda

•

Difficulties of being recorded (this changes the

very nature of the consultation)

•

More difficult to assimilate information

•

Difficulty interpreting symptoms & signs

•

Deal with a greater workload

•

Easier when patients only want reassurance

•

May speed decision making in acute situations

•

Patient expectation - people expect visits

•

Misunderstandings may occur

•

Difficulties less if own dr.

•

What if no phone?

Stages of a telephone

consultation – achieving a

high quality outcome

Q

u

a

l

i

t

y

i

n

t

e

l

e

p

h

o

n

e

c

o

n

s

u

l

t

a

t

i

o

n

s

1

.

I

d

e

n

t

i

f

i

e

s

r

e

a

s

o

n

f

o

r

p

r

e

s

e

n

t

a

t

i

o

n

2

.

D

e

f

i

n

e

s

p

r

o

b

l

e

m

Q

u

a

l

i

t

y

i

n

t

e

l

e

p

h

o

n

e

c

o

n

s

u

l

t

a

t

i

o

n

s

3

.

S

h

a

r

e

s

p

r

o

b

l

e

m



4

.

M

a

n

a

g

e

s

p

r

o

b

l

e

m

Q

u

a

l

i

t

y

i

n

t

e

l

e

p

h

o

n

e

c

o

n

s

u

l

t

a

t

i

o

n

s

5

.

E

n

d

s

C

o

n

s

u

l

t

a

t

i

o

n

Stages of a telephone consultation

HANDOUT

1.

Preparation

2.

Introductions

3.

Gathering information

4.

Diagnosis/ decision making

5.

Action plan

6.

Concluding the call

•

Any information available –previous

consultations, results,

•

Check records

•

Pre-plan what consultation might be

about (if information is clear)

•

Always introduce yourself by name and

mention your organisation.

•

If the caller is not the patient, why not-

establish/confirm the identity of the caller

and relationship to the patient (and

consider any implications for

confidentiality).

•

Try to speak directly to the patient if

possible/appropriate.

•

A first hand history tends to be more

reliable although there are clearly

situations when an additional history from

a third party will be valuable.

•

Establish trust and rapport

•

Empathise - few patients, no matter

how offhand they seem, take the

decision to call lightly.

•

An initially prickly, demanding manner

may be fuelled by anxiety, so

empathise when you take the call,

e.g.: "I hear (x) has a nasty sore

throat, tell me all about it".

•

A second call for the same patient

within a short time frame often

requires a more careful and thorough

triage as statistically it is more likely

to indicate a more significant clinical

problem which requires a face to face

consultation.

•

Start with open questions

•

Listen to the caller and give enough time

to place yourself in a position to assess

what they are saying.

•

Allow the caller to give their own account

of the problem in their own words with the

minimum of interruptions.

•

Focus on clinical aspects only when you

have established: the reason(s) for the

call; and the callers ideas, concerns and

expectations

•

The 5 'W's are useful guides:

–

What is the problem?

–

Where does the problem occur?

–

When does the problem happen?

–

What makes the problem better or

worse?

–

What is the timeframe for the

problem?

•

Open and closed questioning

•

Avoid repetition as this diminishes the

confidence of the caller.

•

Deliver questions/information in a clear

manner, without 'waffling or padding' or

'beating about the bush'.

•

Establish caller's agenda

•

Establish callers ideas, concerns,

expectations

•

Summarise and check understanding

4. Diagnosis/ decision making

•

Making a differential diagnostic map

(consider the important ‘not to miss’

diagnoses – even if unlikely)

•

Flexible approach to decision making –

options will exist – which are safe and

acceptable?

•

Empower caller to take action where

possible – involve in decision making

•

Negotiation

•

Clarify what action you will take

•

Check understanding

•

Plan agreed

Possible outcomes:

i.

Information or advice only is required

ii.

A face to face consultation with a GP or

a nurse is necessary – at home, in the

surgery, out of hours centre

iii.

A consultation with others is needed

(999 Ambulance, A&E, Community

Nurse referral, Social services)

RCGP SCORESHEET

•

Listen to these calls and score them

•

Discussion

ROLE PLAYS

W

h

a

t

d

e

f

i

n

e

s

e

x

c

e

l

l

e

n

c

e

i

n

t

e

l

e

p

h

o

n

e

a

s

s

e

s

s

m

e

n

t

?

Advanced Telephone

Communication Skills

W

h

a

t

i

s

r

e

q

u

i

r

e

d

i

n

g

o

o

d

T

e

l

e

p

h

o

n

e

A

s

s

e

s

s

m

e

n

t

Good Telephone Assessment requires;

•

Training, because it requires/needs;

•

Skill

•

Structure

•

Techniques

•

Critical thinking

•

Practice

•

Expert communication skills

Symptom assessment is rarely cut and dried,

and evaluating patients without being able to

see them presents the fundamental challenge

of  telephone management.

W

h

a

t

i

s

r

e

q

u

i

r

e

d

i

n

g

o

o

d

T

e

l

e

p

h

o

n

e

A

s

s

e

s

s

m

e

n

t

Acknowledge that it comes more easily for some

than for others due to;

•

Personality

•

Confidence

•

Voice

•

Experience

A number of studies have identified substantial

variation in the quality of telephone

consultations/assessments

Caller’s have expectations and what they want

generally:

• to know who they are speaking to

• to get a timely response

• empathy and recognition of their anxiety and

recognition of their concerns

• empowerment to deal with and to know what

they can do about, their problem

• to know what to do if things change / get

worse

•

Identify yourself CLEARLY by name and the

organisation you work for.

•

Apologise if there is delay in response

•

Start with an open question: How can we

help you? What’s been happening with …..

What’s the situation with ….. What can we do

for you…..

•

Or “I understand that you are experiencing  a

fever/diarrhoea/back pain

•

Open early with an empathic / empathetic

tone “I’m led to believe that your are

concerned about your child ……Jade/ Kylie

etc

•

Use active listening.

•

Make yourself interested.

•

Concentrate on their words not your ideas.

•

Use mmm’s, ahaa’s and empathetic ahhh’s

as appropriate

•

Pick up on cues, reflect these back with a

question

•

Use open questions : “How, What, Where,

When, Which

•

Use “Why” carefully or avoid it.

•

Allow the caller to voice their concerns &

acknowledge their concerns

•

Enhance by clarifying and summarising

S

t

r

u

c

t

u

r

e

Use the toolkit as a guide .i.e

•

Elicit call reason

•

Identify emergency SX

•

PMH, DH

•

Assessment

•

Management

•

Prescribing

•

Safety netting

•

Rapport

P

r

o

b

l

e

m

a

n

d

P

a

t

i

e

n

t

H

i

s

t

o

r

y

U

s

i

n

g

S

C

H

O

L

A

R

f

o

r

p

r

o

b

l

e

m

h

i

s

t

o

r

y

•

S

y

m

p

t

o

m

s

a

n

d

a

s

s

o

c

i

a

t

e

d

s

y

m

p

t

o

m

s

I

s

i

t

a

n

i

s

o

l

a

t

e

d

s

y

m

p

t

o

m

o

r

c

o

m

p

l

e

x

o

f

s

y

m

p

t

o

m

s

?

C

o

u

r

s

e

o

f

s

y

m

p

t

o

m

s

:

I

s

i

t

b

e

t

t

e

r

?

W

o

r

s

e

?

T

h

e

s

a

m

e

?

•

C

h

a

r

a

c

t

e

r

i

s

t

i

c

s

(

a

i

d

s

i

n

p

r

e

c

i

s

e

d

e

s

c

r

i

p

t

i

o

n

)

Q

u

a

n

t

i

t

a

t

i

v

e

(

s

c

a

l

e

o

f

1

0

)

Q

u

a

l

i

t

a

t

i

v

e

(

s

h

a

r

p

,

d

u

l

l

,

p

o

u

n

d

i

n

g

)

•

H

i

s

t

o

r

y

o

f

c

o

m

p

l

a

i

n

t

I

n

t

h

e

p

a

s

t

:

W

h

a

t

w

a

s

d

o

n

e

?

B

y

w

h

o

m

?

W

h

e

n

?

R

e

s

u

l

t

s

?

•

O

n

s

e

t

o

f

s

y

m

p

t

o

m

s

W

h

e

n

s

t

a

r

t

e

d

?

H

o

w

l

o

n

g

p

r

e

s

e

n

t

?

S

u

d

d

e

n

o

r

g

r

a

d

u

a

l

?

(

S

u

d

d

e

n

=

h

i

g

h

e

r

a

c

u

i

t

y

)

•

L

o

c

a

t

i

o

n

o

f

s

y

m

p

t

o

m

s

:

S

t

r

i

v

e

f

o

r

p

r

e

c

i

s

i

o

n

.

R

a

d

i

a

t

i

o

n

?

(

l

o

c

a

l

i

z

e

d

=

h

i

g

h

e

r

a

c

u

i

t

y

)

•

A

g

g

r

a

v

a

t

i

n

g

f

a

c

t

o

r

s

W

h

a

t

m

a

k

e

s

i

t

w

o

r

s

e

?

•

R

e

l

i

e

v

i

n

g

f

a

c

t

o

r

s

W

h

a

t

m

a

k

e

s

i

t

b

e

t

t

e

r

?

•

Bad openings, “yawn, Hi it’s the OOH doctor

here”

•

Interrupting the patients story / narrative

•

Not finding out why they have called and

their concerns

•

Making an assumptions early in as to what is

wrong with the patient and what the outcome

is going to be

•

Not sounding confident

•

Lacking focus

C

o

m

m

o

n

P

i

t

f

a

l

l

s

The most common of these pitfalls

include;

•

Inadequate time taken on the call

•

Insufficient history taking and

documentation

•

Stereotyping of clients and problems

•

Second guessing or over-reliance on

callers

•

Premature closure

S

t

e

r

e

o

t

y

p

i

n

g

•

We can avoid stereotyping symptom

patterns by careful and sensitive

assessment of problem and patient

history, and by taking care not to jump

to conclusions.

•

For example, burning on urination in an

older female cannot simply be

dismissed as a urinary tract infection; it

may be symptomatic of a sexually

transmitted disease.

A

s

s

u

m

p

t

i

o

n

s

•

Being dismissive of the caller's

concerns

•

Callers who claim that the problem is

an emergency may have correctly

assessed the situation

A

s

s

u

m

p

t

i

o

n

s

The caller who has self-diagnosed a problem may give

a false sense of security.

•

For example, the caller who begins by saying: "My

new medication makes me feel dizzy" or "I was

carrying some logs and now my shoulder really

hurts" or "I think I have the flu" may have seriously

misrepresented the problem.

•

 The initial patient description must be set aside and

more details are elicited

•

You cannot simply assume that symptoms are a

result of a medication, musculoskeletal injury, or the

flu. Those complaints could be related to conditions

like stroke, myocardial infarction, or sepsis, for

example.

•

Salience is defined as being particularly noticeable,

striking or relevant

•

A major task in telephone assessment is to

determine what data are relevant and which are not

•

While key symptoms may be salient, others that are

more general and nonspecific may be given less

weight.

•

There will be information that is irrelevant and must

be consciously ignored in order to come to safe

decisions.

•

Experts have found that too little or too much

information impairs critical thinking

•

A

r

u

l

e

o

f

t

h

u

m

b

i

s

a

w

a

y

o

f

p

r

o

c

e

e

d

i

n

g

b

a

s

e

d

o

n

e

x

p

e

r

i

e

n

c

e

a

n

d

s

o

u

n

d

j

u

d

g

m

e

n

t

.

R

u

l

e

s

o

f

t

h

u

m

b

p

r

o

v

i

d

e

a

p

r

a

c

t

i

c

a

l

m

e

t

h

o

d

t

h

a

t

c

a

n

g

e

n

e

r

a

l

l

y

b

e

r

e

l

i

e

d

u

p

o

n

f

o

r

a

n

a

c

c

e

p

t

a

b

l

e

r

e

s

u

l

t

.

•

Be alert to possible atypical, silent, or novel

presentation

•

Always speak directly with the patient when possible.

Many calls are mis-triaged by not taking the extra

effort to speak directly with the patient. This strategy

will not only improve the quality of information

collected, fostering trust and compliance, but it can

also expedite the call

•

The more vague the symptoms the greater the need

for good data collection.

•

Speed does not equal competence; avoid premature

closure.

"

T

e

l

e

c

h

a

r

i

s

m

a

“

i

s

t

h

e

w

a

y

w

e

c

o

m

e

a

c

r

o

s

s

t

o

t

h

e

c

a

l

l

e

r

/

p

a

t

i

e

n

t

•

From the first words of greeting, and from the way

we listen, respond, and ask questions, we need to

demonstrate we are listening, are interested

•

Make the time to listen to you own calls

•

Know what you sound like, your tone , manner, pitch

all accentuated

•

Words or phrases that you say and you do not not

realise what you are saying or how you are saying

them

U

s

e

O

p

e

n

-

E

n

d

e

d

Q

u

e

s

t

i

o

n

s

•

Open-ended questions provide for better and

more reliable data gathering by encouraging

the clients to perform the work of describing

symptoms.

•

Example; can you describe the pain for me?

                     what does the diarrhoea look like?

                     tell me about your breathing

—eliminate yes or no responses. Always start

data collection with open-ended questions.

•

Asking leading questions—a flawed technique often

related to being time-driven—simply elicits yes or no

answers, thereby yielding faulty data.

•

Resist using leading questions, which cloud the

picture by providing the answer in the question.

•

For example: Is the pain severe? Are you having

bloody stools? Are you having difficulty breathing?

usually elicit yes or no answers

•

For example: you don’t have back pain do you?

                            no back pain?

     usually elicit yes or no answers

•

There are several exceptions to the policy of

utilizing open-ended questioning. Exceptions

include crisis-level calls, the frail elderly and

poor historians

•

In such instances, use facilitative questions

such as: Is the pain better, worse, or the

same as it was yesterday? Is the bleeding

dark red or light red? This is a compromise

between open-ended and leading

approaches that may still yield better data

than leading questions.

•

It is always important to be sure you have

established the "caller's agenda“

•

Sometimes the caller/patient's ideas, concerns

and feelings become evident with more direct

questioning.

•

Sometimes you will have to ask, e.g. "Tell me,

have you any worries about what might be going

to happen" or "have you had any bad

experiences with these sort of symptoms

before? “

    The fear of the throat closing up, the ear drum

perforating or meningitis developing will be out in

the open.

•

Multiple choices that are two numerous and come

too fast for the person who is listening to you

•

For example "Have you  or did you ?1 ... 2... 3.. .4...

•

Avoid jargon

•

Sometimes you can help the caller who is anxious or

angry with the use of "I" Statements.

•

Using 'I' Statements allows a person to 'own' their

thoughts feelings and opinions rather than using

'you' Statements, which may implicitly blame the

other person.

•

When getting a vague history or feel that there is

something the caller/patient is not giving the full

history

•

" I am wondering...."  "I get the feeling that...“ "I have

a sense of..."

•

"I understand that you are angry"

•

"I am sorry that...." Can be an expression of

sympathy only and does not have to imply that

anything was your fault

'I' Statements that disclose your feelings in a

professional manner and create empathy:

•

"I am concerned that"

Having drawn together the information we need to

assess the situation a management plan can be

devised

.

•

Always ask yourself, 

"Is telephone management

appropriate in this situation?".

•

Ensure that the patient understands the instructions

provided and feels free to ask questions and receive

clarification of any information that is not entirely

clear.

•

A caller should receive sufficient information to allow

him/her to manage a disorder at home and

understand when further advice needs to be sought.

•

Share your thinking with the caller,

     i.e. "this sounds highly likely to be a nasty virus" or

"if it was something that I need to see immediately,

such and such would be happening".

•

When giving advice on home care be clear what you

need the patient to do. For example dose, frequency

and for how long

•

Give concrete examples of worrying signs and

symptoms. Explain what to do if your plan is not

working, including when and how to seek help.

•

Give clear, specific, follow up instructions e.g. "If the

pain/temperature has not settled in an hour please

call back“

•

Always check that there is agreement and

understanding of what you propose.

•

It might also be necessary to emphasise your

confidence in your own advice e.g. "yes, I'm sure this

is medically sensible and safe, could we try it for a

while".

•

Patient education should always be

considered if appropriate. For instance, if

someone has rung up about an hour's worth

of sore throat it may be reasonable to politely

say e.g. "Next time this happens you will

know what how to manager it at home

•

When giving home care advice do not give

too much, chose the important advice

•

If symptoms become markedly worse or fail to

respond to the home treatment, the patient agrees to

call back

•

Patient agrees to the plan.

•

Elicit and document what the caller plans to do at the

end of the call. This will demonstrate that there was

agreement to a certain plan of action.

•

F

u

r

t

h

e

r

,

i

t

e

n

s

u

r

e

s

t

h

a

t

t

h

e

p

a

t

i

e

n

t

u

n

d

e

r

s

t

a

n

d

s

w

h

a

t

t

o

d

o

a

n

d

u

n

d

e

r

w

h

a

t

c

o

n

d

i

t

i

o

n

s

t

h

e

y

m

a

y

n

e

e

d

t

o

a

s

k

f

o

r

f

u

r

t

h

e

r

h

e

l

p

.

•

Request caller to repeat advice if felt necessary

•

Let caller disconnect first.

•

Must be consistent/ mirror verbal

assessment and advice

•

Unambiguos

•

Clear and Accurate

•

Understandable

QUESTIONS?

Have we addressed your learning

needs?