Navigating Difficult Telehealth Encounters: What You Say and How You Say It Matters
The goal of telehealth nursing triage is to help patients get to the right care, at the right place, and the right time. In every triage encounter, the nurse must quickly build rapport and establish a trusting relationship. This allows the nurse to partner and collaborate with the patient to get the care they need. However, some patient interactions can be more challenging. For example, the patient may have a different agenda or expectation of the encounter. Establishing rapport with patients who are very anxious, worried, or angry can be especially challenging.
Navigating difficult calls requires specific communication strategies which help the telehealth nurse:
Establish a trusting relationship with a patient.
Identify the patient’s needs and expectations, including hidden agendas.
Mitigate anxiety and anger when needed.
Set boundaries when needed to ensure the safety and dignity of both the patient and others (including the nurse).
Studies Show That How We Communicate Matters
Establish a Trusting Relationship
One study showed that the first 10 to 20 seconds of a phone call “significantly affects the patient’s perception of the nurse, and the ability and desire of the nurse to meet the patient’s needs.”1
A good start to any triage call is to employ generous and active listening. The triager will soon detect what (if any) symptoms need to be triaged, and if the caller is upset, angry or frustrated.
Voice tone, quality, pace of speech, word choice, enunciation as well as an energetic and caring attitude all support a nurse triager’s effectiveness. This helps in building rapport, conveys confidence and helps to show genuine interest and “willingness to help” a patient.2, 3
Identify the Patient’s Needs and Expectations, Including Hidden Agendas
Per Betancourt et.al. “Effective clinician-patient communication is directly linked to improved patient satisfaction…. including patient safety.” 2 The quality of our communication can impact patient safety outcomes.
Word choice is also very important when looking for additional (hidden) concerns in a triage call. One study showed that a patient is more likely to respond yes when asked:“Is there something else you would like to discuss today” as opposed to “Is there anything else you would like to discuss today?”4 The word something subtly prompts a “yes” answer, whereas the word anything infers an expectation of a “no” answer.
Mitigate Anxiety and Anger When Needed
The ABCDE method of dealing with difficult callers is a useful tool. It is included in the adult Schmitt-Thompson Difficult Call telehealth triage guideline.5 The ABCDE method is especially helpful for mitigating anxiety and anger.
A Accept that this can be an unpleasant phone call (or message). Take some calming breaths and put on your Teflon overcoat.
B Set Boundaries. It is inappropriate for you to be the target of foul language or physical threats. It is right and appropriate for you to set boundaries with the caller. For example, if the caller is using foul language you might say "I want to do my best to try to help you this evening. However, if you continue to use bad language I will need to end this call."
C Show Concern and compassion. Verbalize empathy. Give the caller a chance to "vent." Use the verbal tool of "Blameless Apology." Provide reassurance and support.
D Identify what the caller thinks is the main problem (true reason for call) and then work with the caller to create a solution. Strive for alignment with the caller. Use the verbal tool of "Saying YES." Decide upon a Disposition.
E Enlist help from others. This can be family members, neighbors, social workers, the patient's doctor(s), other healthcare providers, local agencies, and the police.
Tips for Specific Difficult Call Situations
Risk of Harm to Self or Others
In some difficult call situations, there is a serious risk of harm to the patient or others.
Examples are patients who threaten to harm themselves or others, or patients who sound very confused or lethargic.
In these situations, the nurse triager should use the appropriate guidelines: Suicide Concerns, Homicidal Threats or Attempts or the Confusion - Delirium guideline.
The triager can enlist others to call EMS-911 while staying on the phone with the patient.
Caller Who Is Overly Worried and Difficult to Reassure
A caller who is anxious or overly worried may call repeatedly about the same or similar concerns. These types of calls can take longer than usual.
Ascertain that there are no new symptoms or that symptoms are not getting worse. Guard against being complacent towards these callers. The caller may have new or concerning symptoms that have not been addressed.
Offer genuine reassurance for positive self-care habits and observations.
These callers may benefit from an outreach care plan, with scheduled check-in calls or a visit. Working with the caller’s PCP to align care and reinforce the patient’s care plan can be helpful.
Caller Who Does Not Provide Enough Information for Triage
Let the caller know you would like to hear more about their symptoms so you can better assist them. If the caller is unwilling to disclose further information, treat the call as a general information type of call. It is unwise to give a specific disposition without all the facts.
Encourage the caller to call their PCP if they feel more comfortable or to call back when they are able to share more details. Remind the caller that for life-threatening symptoms, they will need to call EMS-911.
Document the triager’s repeated request for further information and that the patient declined to give additional details.
Caller Who Is Threatening Retaliation (e.g., Against Organization, Specific Provider)
Allow the caller to vent their concerns. Document the caller’s statements.
With a calm voice, let the caller know that their concerns have been heard and that you will pass these along to the appropriate person or department.
Follow your organization’s policy for threatening or hostile calls.
Caller Who Is Verbally Abusive
Many organizations now have a zero-tolerance policy for abusive language or behavior.
A call center or office policy can address an escalation process for an abusive caller. Scripting may remind the caller that we are here to help them, but they will need to refrain from hostile or abusive language. If the caller continues with abusive language, a policy may direct the triager to notify the caller to call EMS-911 for emergent situations, and that the call will need to be terminated if the abusive language continues.
Maintain a calm voice. Keep the call brief.
A policy may include leadership notification, an escalation process, and thorough documentation of the call (or message).
Alerting triage colleagues of the recent call will help all staff to be prepared for further calls and to approach the call in a consistent manner. An organization may have a feature to flag a chart with observed patient behavior and what steps were taken by the triager.
Caller Who Is Inappropriate
Some callers are inappropriate with their conversation or requests (for example, inappropriate sexual conversation). First ensure that the caller is in a safe situation and does not have symptoms that require triage. The triager can let the caller know that their remarks are inappropriate and the triager will need to terminate the call should the behavior continue.
Follow your call center policy for patient scripting and call termination process. A policy may include notification of risk, legal and security departments, and possibly local police. Call pattern tracking of date, time, name, address used, and nature of call is helpful for follow-up.
Other approaches may include a certified letter which may prohibit use of the triage line, blocking the caller’s phone number to the triage line (for example, a 30-day block) or a filed police report. These types of calls may interfere with access to your call center, which may be against the law in your state.7
Spoofed Phone Numbers
Difficult callers may “spoof” their calls, which involves using a different phone number as their own, to falsely disguise their caller ID and identity.8
If you suspect spoofing, you can contact your local police, who may help identify the source.
Document all phone numbers being used, along with the associated date and time of each call.
Post-Call Support and Debriefing
A patient may have a variety of reasons for calling, is usually ill or caring for someone that is ill, and may be experiencing frustration, fear or a loss of control in some aspects of their health. Verbal filters may be reduced, and a caller may have difficulty articulating their needs in a therapeutic manner. This can lead to evasive, rude, hostile or aggressive phone manners from some callers.
As part of a call center policy, the triager may need to take a break from calls and debrief with a supervisor or coworker. These types of calls may be traumatic and disturbing.
The American Academy of Ambulatory Care Nursing has a helpful Workplace Safety Toolkit, located at Home | American Academy of Ambulatory Care Nursing (https://www.aaacn.org).
Train and Prepare Telehealth Nurses to Handle Difficult Calls
Recognizing difficult call situations and responding appropriately requires practice and training.
Orientation: Review policies and resources, as well as communication strategies.
Practice mock calls.
Review difficult call situations with staff.
Using specific communication techniques helps ensure a successful resolution of the patient-nurse interaction that supports the patient’s needs and optimizes patient satisfaction. Knowledge of organization policy on managing the verbally abusive or inappropriate caller will prepare the triager to set firm boundaries when needed, to ensure the safety and dignity of both the patient and triager.
Co-Authors
Cheryl Patterson, RNC-TNP, BSN, Nurse Editor, Adult Clinical Content
Jeanine Feirer, RN, MSN, Nurse Editor, Adult Clinical Content
References
1 American Academy of Ambulatory Care Nursing. (2011) Telehealth Nursing Practice Core Course. (2nd ed.). Pitman, NJ: Author, p. 44.
2 Betancourt, J., et.al. The patient's culture and effective communication. UpToDate. Waltham, MA: UpToDate Inc. https://wwwuptodate.com/contents/the-patients-culture-and-effective-communication. Accessed February 9, 2025.
3American Academy of Ambulatory Care Nursing. (2011) Telehealth Nursing Practice Core Course. (2nd ed.). Pitman, NJ: Author, p. 46.
4 Robinson JD, Opel DJ. Word Choice and the Patient Encounter. JAMA. 2024;332(15):1296-1297.
5 Difficult Call After Hours Telehealth Triage Guideline (Adult). Copyright LMS Inc, Schmitt Thompson Clinical Content, 2024.
6 50 Inspirational Quotes, https://letslearnslang.com/inspirational-quotes.
7 https://app.leg.wa.gov/rcw/default.aspx?cite=9A.50.020.
8 https://www.fcc.gov/spoofing.