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Telephonic Hospice Nurse: Interview with Robert Zack, RN

By Mariah Williams
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WORKING NURSE MAGAZINE: What type of nursing do you currently do, Ron?

RONALD ZACK, RN:  I am an after-hours telephone triage nurse for a hospice.

How did you become involved in this line of nursing?
I had been a nurse for about 18 years when I was introduced to hospice. At the time, most of my experience had been in emergency nursing, home health, and psychiatric nursing. Over the past 12 years, I have worked for various hospices, both in Arizona and in California. For the first nine of those years, I worked as a case manager, seeing hospice patients at their homes and in facilities. Much of the time, I worked after hours or on-call.

Often, when working nights or weekends, if a call came into the hospice, I would take the call, either manage it over the telephone, or make a visit. As patient loads grew, many hospices began to use a dedicated telephone triage nurse to take calls and, if necessary, dispatch a dedicated visit nurse or another provider, such as a social worker or CNA, to the patient's location. I began to do that job and have continued, part time or per diem, over the past few years.

What kind of training does this type of nursing require?
Hospice training is essential. Many hospices offer a fairly intensive orientation and on-the-job training. There is also a great deal of continuing education available from organizations such as the Hospice and Palliative Nurses Association. A core curriculum and certification is available.

There is no specific training for telephone triage, as it relates to hospice, but substantial experience as a hospice nurse case manager is very helpful.

What does your work involve on a daily basis?

A typical day generally runs from 5:00 p.m. till 8:00 a.m. and, on weekends, from 5:00 p.m. Friday to 8:00 am Monday. I receive reports by voicemail or email. Calls come to me from the answering service and, unless I am on another call, the service will patch the caller through to me. The call may involve a patient's symptoms, equipment, supplies, or medication. I often need to refer to specific patient information via internet or a detailed printed census that has been faxed or emailed to me. Based upon the problem, I may suggest a course of action, or I may offer to send out the nurse, the DME technician, or a social worker. On weekends, I often have the option of sending a CNA if that would be helpful.

Sometimes the call is as simple as a medication refill. Sometimes it is a change in condition that results in significant discomfort for the patient and/or family. A considerable amount of teaching is often involved.

Death calls present an interesting dynamic. Since hospice staff must attend all home deaths, we instruct families and caregivers to call us first. Many find it difficult to say “dead.” They might say, “He hasn’t been breathing for 10 minutes and I can’t wake him up,” or “I think he might be gone, but I’m not sure.” I have to be able to read the caller’s response, find the right words, and prioritize the visit. Sometimes the family wants a little private time and other times they need someone there as quickly as possible.

I also receive calls from doctors with new orders, from hospital case managers with referrals, and sometimes general questions from people in the community. If I receive a referral, I need to act on it—setting an appointment for an evaluation, contacting a doctor for orders, or providing further information to family or caregivers. The field nurses will also call to report the outcome of a visit, or to ask my help brainstorming a solution to a problem. At the end of my shift, I report over voicemail and email and I fax or email my documentation.  

That sounds very interesting and definitely outside the box of what we typically think of in nursing! How long have you worked for this organization, and how did you choose to work there?
I have been with my current company for a year and a half, but have done telephone triage for about three years. I chose this company because I was familiar with many of the people involved in its start-up and I was offered an opportunity to participate in the growth. Over the past year and a half, the patient census has doubled.

What types of rewards come with this kind of nursing?
I like the challenge of analyzing and solving problems from a distance. The job requires me to maintain my clinical knowledge of symptom management, and to utilize a variety of psychosocial skills. It is rewarding to be able to calmly deal with a family in crisis and help them work through the situation.

Also, the flexibility is a huge plus.  I am able to work from home or from anywhere I happen to be. My home, in fact is in Arizona, and the hospice I work for (and all of the patients I deal with) is in California. I have done triage while on vacation, working from my cell phone and laptop in a hotel room. As I also work another job and sometimes travel, I can continue my triage assignments at night. The triage job is very compatible with another schedule.

Any less agreeable aspects or challenges?
As in any job, there are frustrations. The phones get busy at times. Since the goal is always to give each caller my undivided attention, I sometimes need to budget my words carefully.

Dealing with staff can sometimes be difficult. As a triage nurse, every time I call someone, I am asking them to do something—to work. Often, people in the field are stretched pretty thin and they must cringe when they see my number on their caller ID.  Sleep deprivation can also be a problem. My body has adjusted over the years and I can wake up easily and fall back asleep quickly. Fortunately, I can get by with multiple short naps through the night.

What would you say to encourage nurses looking for a specialty to explore this one?
I would suggest having a year or two of hospice experience first. This is not necessarily an area of nursing for everyone and experience in hospice nursing can help you determine that. Also, because the hospice triage nurse often must operate independently, it is important to have a solid knowledge base about death, dying, symptom management and about grief and bereavement.   


National Hospice and Palliative Care Organization,
Hospice and Palliative Nurses Association, 

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