How triage nurses use discretion: A literature review

Guidelines

The most central aspect of a formalised triage system is the triage guidelines. Their purpose is to provide criteria for classifying patients in clear-cut categories of urgency. When applicable, these criteria provide a strong basis for prioritising patients. There was, however, consensus among nurses in the reviewed literature that guidelines are insufficient for establishing priorities. Nurses’ views of guidelines varied from those who state they are “a reference for triage decision making” (4, p. 210) to those who claim guidelines are “a detrimental influence to expert patient assessment” (5, p. 404).

The most positive view of guidelines was expressed in Johansen and Forberg’s (13) study. Here, nurses praised the triage guidelines for providing a higher degree of overview and more assurance and control compared with previous practice, thus making it easier to prioritise patients. However, the nurses in this study did not view triage guidelines as a panacea; they said that they were careful not to rely blindly on the standardised guidelines. Instead, they stressed the importance of being critical and using their nursing experience as a supplement when triaging.

One reason for supplementing the triage guidelines was that they were said to be too simple to match the complexities of patients and their complaints (4, 13). For instance, a nurse in Chung’s (4) study complained that “[t]he guidelines provide limited and fixed information that might not be adapted to the real situation when you handle the patient. Sometimes, you cannot find a suitable category to match a patient’s case according to the guidelines.” (p. 210) In other words, the nurse complained that some patients elude the guideline’s distinctions. Similarly, the literature contained several references to “borderline cases” (1, 4, 13, 14), which fell between two categories of urgency and often generated uncertainty and stress for the nurses. The literature portrayed the problem of “borderline cases” as twofold, since patients were “borderline” either when they presented with too little or too much information. Too little information made it difficult for nurses to relate a patient to the guidelines (12). Too much information, on the other hand, made it difficult to use the standardised triage manual because of a potential conflict between the guidelines and nurses’ situational knowledge of the patient (13).

Nurses in some studies considered triage guidelines redundant or even obstructive for experienced nurses’ practice (4, 5, 13, 14). For instance, the expert nurses in Cone and Murray’s (5) study stated that they did not need to follow guidelines to make decisions; on the contrary, they claimed that guidelines could hinder them in their practice. A beginner nurse, on the other hand, was described as having little clinical experience and therefore being more dependent on following specific rules when assessing patients since, in the words of one expert nurse, “she has nothing to build on… nothing to make decisions from… no experience” (5, p. 405). The views in Cone and Murray’s (5) study were those of experienced nurses with at least five years of ED experience, whereas Patel et al. (14) found that both beginner and experienced nurses expressed a similar view. The less experienced nurses said they carefully followed the guidelines most of the time, while the most experienced nurses claimed to have “internalised” the guidelines and stated that they use these alongside their own judgment.

Work environment

Most studies reported that the information-gathering work of triage nurses occurs in a hectic work environment (1–4, 9, 12–14). The studies described how EDs often receive a large amount of patients at the same time; to facilitate patient flow and identify the most urgent patients, nurses therefore assessed all patients in as short a time as possible (1). This is necessary to avoid “triage overload” (12), in which the influx of patients exceeds nurses’ capacity to triage them. In addition to the number of patients who present, “triage overload” was said to be related to the complexity of patients’ complaints; complicated problems, such as patients presenting with mental illness (9), require more time than uncomplicated ones and could therefore lead to access block (12). Several studies also showed triage nurses to be vulnerable to interruptions in their work (1, 2, 4, 8): for instance, when patients approach the triage area demanding immediate attention (1).

Several studies argued that a hectic work environment complicates nurses’ decision-making. The need to make prompt decisions could generate uncertainty and stress (13) and make nurses miss critical cues (2). Similarly, interruptions could distract nurses and cause them to overlook important information (4). In these situations, nurses risked assigning patients too low an urgency level and thereby “undertriaging” them. Conversely, the work environment could also facilitate “overtriage”. When the patient volume was high and the waiting time long, nurses sometimes gave patients a higher urgency level to decrease the risk of their condition deteriorating while waiting (4). Furthermore, this tendency to “overtriage” was exaggerated by nurses wanting to avoid legal sanctions for failing to detect acutely ill patients (2, 4). Therefore, in sum, the working conditions of triage made it challenging to perform urgency assessments.

Use of experience and intuition

In several studies, nurses named the use of previous experience to be one of the most salient resources in their decision-making (3–5, 10, 12, 14). We should note, however, that “previous experience” is conceptualised in different ways in different studies. In some studies, previous experience is described as a repertoire of typical cases that could be utilised in the assessment of patients. This concept is captured in Edwards’ (6, 7) notion of “usual presentations”, which he has adopted from Tanner et al. (1993). Edwards defines “usual presentations” as nurses’ mental representations of how patients typically respond to the problems they encounter, and he suggests that these are constructed through nurses’ experiences with a multitude of patients. Edwards claims that these “usual presentations” act as a basis for comparison in the assessment of a particular patient and, as such, enable nurses to detect whether the patient is critically ill. With reference to Polanyi (1958), Edwards labels this recognitional ability “connoisseurship” and argues that it forms the basis of the expert clinician’s ability to discriminate between patients.

In other studies, previous experience referred to concrete and sometimes singular events, as evident when nurses explained how recent, impressive experiences sometimes affected their decision-making (4, 12). An example of this is “learning the hard way,” which was described as follows by a nurse in Hitchcock et al.’s (12) study:

Another example involved nurses remembering a significant case when assessing a particular patient. Two participants in Chung’s (4) study told of how recent experiences had assisted them in revealing critical conditions in patients that seemingly presented with non-significant symptoms. With reference to Cioffi (1998), Chung termed this decision-making device a “representative heuristic,” which involves using relevant past experiences as a mental shortcut for making quick judgments.

Closely related to the theme of previous experience, studies also revealed that nurses used “intuition” when assessing patients (1, 2, 4–6, 13, 14). Nurses claimed that their intuition provided crucial guidance for triaging patients; even the guideline-friendly nurses in Johansen and Forberg’s (12) study stated that it strongly influenced their decision-making. Intuition was often mentioned in tandem with experience, albeit in less concrete terms; nurses referred to it as a “gut feeling” (5, 6, 13, 14), “gut sense of urgency” (2, 5) or “sixth sense” (1, 4). In an attempt to clarify the concept, Andersson et al. (1) defines intuition as “an instinctive method of thinking, acting and using common sense” (p. 142). They also reference King and Appleton (1997), who has suggested that intuition results from having seen and learned from similar cases. In this manner, intuition becomes strikingly similar to the concepts of previous experience and usual presentations. There is some support for this association in the reviewed studies; many nurses believed intuition to be a distinguishing trait of experts in their field, which is developed through extensive experience and knowledge (2, 5).

The conflict between intuition and triage guidelines was a recurring theme in the reviewed literature. The nurses in Johansen and Forberg’s (13) study pointed out that intuition sometimes complicates patient assessment by making the situation more complex and difficult to reduce to the standardised process laid out by the guidelines. In other studies, intuition was even said to override the guidelines (1, 2, 4, 14). For instance, the experienced nurses in Patel et al.’s (14) study said that when there is discrepancy between the two, they prefer to “go with their gut feelings” (p. 512) and disregard the guidelines. Similarly, a nurse in Chung’s (4) study stated that, “sometimes the data does not reflect the problem of a patient. However, when you feel something wrong about the patient, you give them a higher priority.” (p. 210). Consequently, what Chung (4) terms “subjective information” had significant influence on the decision-making of nurses in these studies.

Evaluative criteria

The reviewed literature described several non-guideline-determined criteria used by nurses to evaluate patients’ complaints, with the most salient of these being appropriateness and believability. The former was used to judge whether a condition fits the ED’s purpose of treating the acutely ill (7, 8, 11). This was central to what Fry (8) describes as triage nurses’ “belief system,” which provides “meaning for how patients should prepare their arrival, act in the emergency department, interact with and respond to the nurse’s efforts” (p. 121). She lists seven of these “beliefs,” and the seventh, “do not waste time,” is of particular relevance here. Nurses in Fry’s study considered patients with “trivial conditions” as violators of this norm. Trivial conditions are those that “the patient could treat him or herself, needed no treatment, were minor or chronic and could be managed by a Medical Centre or GP” (8, p. 124): in other words, conditions that are considered inappropriate for the ED. Patients presenting with trivial conditions were believed to waste resources and put sicker patients at risk. When nurses encountered these patients, Fry observed manifest changes to the assessment process. Nurses shortened the duration of the process and reduced patients’ urgency rating. Moreover, they expressed resentment towards these patients. One nurse told Fry, “If I could give a [triage] code 10, I would. They deserve it” (8, p. 124). Fry interprets this statement to indicate that some patients were less deserving of ED services, in this case because they breached the values of appropriateness and efficiency. Hillman (11) makes the same claim, but she also stresses that nurses’ judgments are not fixed; instead, “trivial” patients may influence nurses’ triage code allocation by providing reasons for their presence in the ED. Nonetheless, these studies both suggest that nurses perform moral evaluations of and respond emotionally to patients in the ED.

The second criterion, believability, was used to judge the trustworthiness of patients’ complaints (3, 7, 11, 14). Edwards and Sines (7) considers this criterion particularly salient in emergency medicine. They reference Hughes’ (1988) suggestion that emergency nurses’ interactions with patients are pervaded by scepticism because of how often they have to deal with people who may be dishonest in their presentation. This scepticism is documented in the reviewed literature, which is rich with descriptions of how nurses use behavioural cues to judge the reliability of patients’ stories. One method was to contrast what patients say with how they walk in and out of the triage area (6, 7). Nurses believed the latter, especially “walking out”, to be a purer expression of a patient’s problem because it was not performed in front of an “audience” (6). Similarly, patients’ behaviour in the waiting room was treated as indicative of their potential pathology or distress. For instance, Edwards and Sines (7) found that nurses used patients’ expressed levels of distress to judge how worried the patients were about their injuries. In other words, they believed that “if the patient really was worried, he would choose to present himself in a distressed way” (7, p. 2446). This assumption was also found in Arslanian-Engoren’s (3) study, in which a nurse claimed the following:

The extract demonstrates how the nurse used behavioural signs to assess the seriousness of the patients’ complaints. Thus, when patients express a lack of concern for their problem, these nurses also suspected that the problem was of little concern.

Time factors were also used to assess the believability of ED patients (7, 8, 11). Nurses in Edwards and Sines’ (7) study were especially sceptical of patients presenting with injuries more than 48 hours old. They believed this behaviour could suggest that the patient was not acutely ill but instead was exploiting the constant availability of the ED. Another and more specific example was what nurses in Fry’s (8) study termed a “positive bag sign,” which referred to patients who entered the ED with a packed suitcase. The nurses considered these patients to break the norm of “not arriving with expectations” and suspected that they were not acutely ill because they had been able to pack a suitcase before coming to the ED.

Nurses also made inferences about the credibility of the types of people who visited the ED (7, 13). For instance, some nurses used patients’ state of dress and hygiene as measures of the extent to which they took an interest in themselves (7). Moreover, in their study of triage in a paediatric ED, Patel et al. (14) found that the nurses were wary of the information given by caregivers because they believed caregivers could lack health knowledge, misperceive their child’s symptoms or exaggerate the extent of their child’s problem. The nurses therefore employed certain methods to judge the reliability of parents’ information, such as rephrasing or rewording questions to check for consistency. Taken together, these procedures suggests that “believability” was a salient concern for triage nurses in the reviewed studies.

Interacting with patients

Most of the reviewed literature takes it for granted that the triage encounter involves an active nurse who gathers information from passive patients; and if anyone influences nurses’ urgency assessments, it is their colleagues. However, two studies were critical of this conception (7, 11). Drawing on Atkinson (1995), Edwards and Sines (7) criticise the common assumption that patients are just passive purveyors of information. This assumption has masked how “patients are active in the construction of the presentation and interpretation of their problems” (7, p. 2450). Instead of focusing solely on the professional, they suggest that the triage encounter should be viewed as an interactive process in which “participants create, elicit, interpret and negotiate the meaning of the presenting problem” (7, p. 2450). Accordingly, they claim that triage can be regarded as what Goffman (1959) terms a “performance,” in which triage nurses act as an “adjudicating panel” and patients have to “argue the merit” of their case to convince the nurse of their credibility as ED patients. Patients may thus affect how nurses determine their urgency and consequently which urgency rating they are awarded. Hillman (11) echoes this point in her article about negotiations in triage, in which she argues that nurses reward patients who depict themselves as responsible citizens and who are able to provide good reasons for their seemingly illegitimate presence in the ED. The findings in these studies suggest that urgency ratings are an interactional rather than an individual achievement, and they have, as we soon will see, significant implications for our understanding of both urgency assessments and discretion.