1. Wiggins, Morgan DNP, APRN, PMHNP-BC


A psych nurse worries about the limits of virtual rapport with patients.


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"Mrs. X can't get a ride for her appointment today. She wants a phone appointment instead," says the message from the receptionist. "Tell her no," is my immediate response. Before hitting send, I scroll through Mrs. X's chart to see if I've ever met her. I wish the receptionist would look this information up before sending me the message, but I know they're understaffed too. Looks like I inherited Mrs. X from a psych NP who left our agency during COVID. We are now two years out from Ohio's first COVID lockdown and the switch to phone and Zoom appointments, and my agency has recently said we should begin to see patients face-to-face at least once a year. Like many of my patients, Mrs. X has not been able to successfully maneuver Zoom, so I've never even seen her face.

Figure. Illustration... - Click to enlarge in new windowFigure. Illustration by Janet Hamlin.

I hit send on my "no" reply and grumble to myself, but I wonder what exactly is bothering me. Yes, the federally qualified health center where I work is understaffed, but this is the type of place where people believe in service to the poor and underserved. I believe in this mission. So where, I ask myself, does my Grumpy Nurse Practitioner Persona come from?


Then I remember that two months into lockdown, a psych NP colleague told me, "This isn't the job I signed up for." I can now admit that I relate to that. I don't enjoy talking on the phone all day, especially since most of these calls are with psychiatric outpatients of high severity. At worst, they are paranoid and responding to internal stimuli. At best, they are guarded, emotionally volatile, and quick to mistrust the motivations of others. If at least 70% of communication is nonverbal, then it stands to reason that only 30% of my phone call visits hit the mark. It also means it's easier for patients to mistrust my motivation or intentions over the phone. After all, they can't see the countless nonverbal gestures I've collected over the years-all designed to illustrate that they're safe with me, that I'm not judging them and don't mean them any harm.


Nor can I see them. Patient appearance is a crucial portion of my assessment. Nothing illustrates functional status quite like attire, grooming, or hygiene. Zoom can show me some of this, but my sense of smell factors into the assessment more often than you'd think. Furthermore, the nebulous psychiatric concept of rapport feels elusive with Zoom. Grumpy Nurse Practitioner feels as though she must squint through 18 layers of wax paper to access emotion on the Zoom screen.


And then there's Mrs. H, who I finally insisted come in for a face-to-face visit. It had started with a phone visit, after which she was hospitalized for a medical complaint and then sent to a skilled nursing facility. After her return home, she expressed confusion over her home care orders, several of which reflected changes to medications I had previously prescribed. No documentation from the nursing facility was available, so I explained to her my concern about the abrupt discontinuation of her psychopharmacologic agents. I advised her to go to her nearest ED, but she declined. When she called several days later to schedule another telephone visit, I insisted that she come in despite her objections. When she arrived, her driver called and said she was too weak to walk to the door.


We ended up carrying her inside.


Her first words were, "I need something for anxiety." I was shocked at the severity of her condition; she was the worst I'd seen her in two years. Her pupils were pinpoints, and she had pronounced right pronator drift. I had to stand on her right side so that she would not fall out of her chair. The entire right side of her body had been weak since that morning. As I directed staff to call the ambulance, she beckoned to me and said, "Something's not right."


Indeed. And I would have missed it on a phone call.


And now I remember a time six months into Ohio's COVID lockdown when my son, then seven years old, was going into school part of the week and doing online lessons the rest. One night, he earnestly explained to me that he should get a "different family," since his parents were too busy to accomplish the online schooling during the lockdown. I began to cry. After I picked myself up out of the hole that swallows bad mothers, I made needed work-life changes to avoid a repeat conversation like that.


And I suspect that Grumpy Nurse Practitioner Persona was born then. She emerged from a fear of failure. A fear that I'm missing something. And she knows, as a certainty, that I'm more likely to fail on the phone.