Issue link: https://nnumagazine.uberflip.com/i/956820
to appropriateness of clinical advice given to whether the RN made enough caring and empathetic statements during the call. Nurses object to being constantly measured against this scoring key, which attempts to micromanage RN behavior. For example, the document states that, "'Good luck' is not considered a sympathetic/ empathetic expression" and that "'Take care' is an acceptable expression but will not be counted as an expression of empathy if it is the only empathetic expression verbalized." As Roth illustrates in her story about the cry- ing baby, advice nurses must be free to complete the entire nursing process using their nursing judgment, knowledge, and skills to deter- mine the best plan for each patient on the other end of the line. "There is a certain number of times I have to say the phrase 'I'm sorry,'" said Billings, "but when I'm dealing with a person with chest pains or try- ing to determine if they have clear airways, that's more important at the moment. The tone of your voice conveys that you are sorry." Kaiser management routinely harps on advice nurses who do not meet their benchmarks for time. In one "Verbal warning—Workflow Optimization" memo to an RN, the RN team manager criticizes her average call handle times as being too long and calls per hour aver- age as being too low compared to regional averages. The clinical out- comes of this nurses' patients were never mentioned or considered; it's clear management only cares about times. Berry said that managers are also pushing the nurses to work faster, to beat the previous regional averages, but the more experi- enced advice nurses know better than to take the bait and are not intimidated by managers. "We don't fall for it," said Berry. "The older nurses are not going to speed up." Roth echoed the others when she explained her approach to calls. "I don't ever try to work faster," said Roth. "I take my time. Every sin- gle patient needs as much time as they need. You can't compromise patient care." If managers hassle her about her call times, she responds, "Are you asking me to standardize my care? To limit my patient care?" Or she points out the many ways that understaffing in other departments is causing her calls to be prolonged. Unfortunately, the AACCs are employing fewer and fewer experi- enced call center advice nurses. The environment is so "harsh," say nurses, that attrition rates are high. Many RNs quit from the stress, medical conditions related to call center work, or have taken early retirement. According to new hire and termination numbers received through a CNA information request, the three Northern California call centers for the period 2010 to 2016 hired 782 RNs but lost 846, for a deficit of 64 RNs even as patient membership numbers have grown by millions. In 2016, the call centers hired only 92 nurses while 191 left. Billings said that she has witnessed entire new hire classes leave within 90 days. Roth says the call centers are also hiring RNs with less and less experience. When she started, AACC nurses needed a minimum of five years of clinical experience. That requirement went down to three to five years, and now it is six months to a year. "When we began, the nurses had decades of experience that they could bring to our call center practice," said Roth. "You need to be able to visualize and extrapolate based on experience. If you can't connect symptoms to a living person at the bedside, you're in big trouble." Trish Gonzalez, a call center RN who worked for many years in pediatrics, said that some nurses believe that call center nursing is an easy job, and they'd be very wrong. "I can't tell you what a high level of care patients receive because of the wealth and breadth of experience that each individual nurse comes with," Gonzalez said. "We're taking care of people with blindfolds and hands tied behind our backs. For anybody who thinks the nurses at the call center are going out to pas- ture, it's not true. Nurses from every background are all work- ing together and really, really taking good care of our patients." To throw another wrench into an already dysfunctional workflow, nurses say that Kaiser's Internet-based call management system, KPATHS, is a disaster. Nurses previously used a system called STARGATE which, while not perfect, was more reli- able. In November 2016, the call centers switched over to KPATHS without notifying or discussing the union or nurses. The results were not pretty. The most distressing KPATHS malfunction happened on May 16, 2017, when the entire system crashed at 9:20 a.m. and normal opera- tions did not resume until 5:05 p.m. According to a report prepared by the nurses, the service disruption resulted in advice nurses losing contact with symptomatic patients, patients stuck in long waits to speak to TSRs as well as RNs, loss of access to interpreter services, and advice nurses forced to handle calls without their protocols and without charting—among a host of other issues. Despite Kaiser's statement, "the crash/outage directly affected Kaiser's ability to deliv- er care," read the report. "The AACC was unable to book appoint- ments, provide telephone prescriptions (TTP), or give advice." Besides the major systemwide crashes and inconveniences of the system, advice nurses are most worried about the extremely long (more than 30, 40, 50 minutes) wait times some callers experience and random crashes or freezes during individual calls, which hap- pen daily. Patient safety is jeopardized when callers get put on hold for such a long time or get disconnected from nurses. "The worst part is when you are in the middle of a conversation and you're not even through the emergent part, and it will freeze and kick the patient off the call," said Berry. "And during interpreter calls, it will freeze up or kick off callers. Each time they do an upgrade, it breaks what was fixed. If we had one straight week without system flaws, we would do cartwheels down the hallway." More than a year later, KPATHS is still crashing. On Jan. 2, the 30 N A T I O N A L N U R S E W W W . N A T I O N A L N U R S E S U N I T E D . O R G J A N U A R Y | F E B R U A R Y 2 0 1 8 "I like my job. I hate the environment. Let people do their job. Stop super micromanaging."