Decisions Of The Triage Nurse example essay topic

DECISION MAKING IN NURSING PRACTICE NURSE TRIAGE IN THE ACCIDENT UNIT MODULE NUMBER: (USA 016 S 2) SEPTEMBER 1998 98000663 WORD COUNT: 4302 For the purpose of this assignment, I have selected to discuss triage nursing in the Accident and emergency department. The assignment will consider how the implementation of the Manchester triage system in the accident unit affects clinical decision making and consider different theoretical decision making frameworks to analyse these effects. I chose the subject of triage for this assignment after a clinical placement in the accident unit. Triage nurses have to make rapid decisions based on their knowledge and experience and the use of the Manchester triage system appears to be a useful and universal tool in the implementation of these decisions although it does have limitations.

I will discuss the limitations and effectiveness of this tool in this assignment. Clinical decision making is a complex process in which nurses choose the type of information that they want to collect, recognise problems from the clues picked up whilst collecting this information and decide upon the appropriate interventions to tackle these problems. (Tanner et al. 1987 and Thomas et al. 1991). The complexity of this process is due to the huge variation in clues presented, the enormity of the information that needs to be processed and the difficulty in predicting outcomes (Hammond, 1960, cited by Pardue, 1987).

Various factors influence the clinical decision making process (Pardue 1987) These include such things as the individual making the decisions, their experience and knowledge (Benner 1984), creative thinking ability, education (Pardue 1987) and self concept (Joseph 1985) as well as environmental and situational circumstances. (Evans 1990). Experience and knowledge are two of the major factors that affect decision making in clinical practice involving much more than just theoretical knowledge. Experience increases the cognitive resources available for interpretation of information which results in more accurate decision making, Intuition, defined by Benner and Tanner (1987) as "Understanding without rationale" represents the hallmark of expert judgement. The ability to quickly identify the relevant and important facts limits the number of alternatives to be evaluated, which in turn reduces the number of decisions to be made. Hamm (1988) developed a system, which he described as The Cognitive Continuum, in order to determine how professionals make judgements.

Hamm believes that human judgement lies somewhere between the two forms of thought of intuition and analysis. The Cognitive Continuum suggests that we do not use just one or the other, but that most of our cognitive activity involves both intuition and analysis. The theory suggests that if the nature of the task is poorly structured, intuitive decision making is evoked, whilst a well structured task would initiate a more analytical approach. Generally speaking, the more clues that are presented, the more likely the professional is to use an intuitive approach. If the problem is complex and the clues ambiguous, then an analytical approach may be used. If applying this framework to system of triage in the accident unit and the use of the Manchester Triage System, it would appear that this theory has a founding.

For example; A 10 year old boy presented to the unit with a history of a simple fall, where he landed on his arm, the presenting arm was very swollen and grossly deformed. The triage nurse had no need to utilise the discriminators and flow charts of the Manchester Triage System. Her own intuition gained from experience and knowledge told her that the possibility of the young mans arm being fractured were extremely high and clinical priority was given accordingly. However, an elderly patient who presented with the same swelling and deformity of her arm, could not explain how or why she fell. She experienced some dizziness but could not say whether she lost consciousness or not before or after the fall.

A different priority was allocated to this patient after consulting the flow charts in order to determine the correct category due to the unknown risk factors of the individual case. The decision made in this case was more objective, the discriminators were not so clear cut so the use of the decision making tool was incorporated alongside the nurses own intuition and experience. Hamm (1988) also describes other factors, which may influence choice, such as the amount of time available for making the decision. If only a short time is available, perhaps due to the critical nature of the situation, an intuitive approach is likely to be used. This again can be seen in the decisions of the triage nurse, simple observation can sometimes be all that is needed to know that someone is "not quite right".

Hamm (1988) believes that intuitive thought involves very quick unconscious "data processing" that combines the information available by "averaging" it, it is low in consistency and fairly accurate. He describes analytical thoughts as slow, conscious and consistent, usually accurate, which combines information by organisational principles. Analysis, by definition, breaks things down so that we can gain better understanding whilst intuition retains wholeness, which may make it more attractive to the nurse for an holistic approach. Benner (1984) applied the work of Dreyfuss and Dreyfuss (1986) on skills acquisition and described five categories of skill level; Novice, advanced beginner, competent, proficient and expert.

Benner suggested that with increased experience, situations are seen less as a minefield of separate tasks and more as a whole problem to be solved. The practitioner will move from being a detached observer to an involved performer. Novices are described by Benner (1984) as beginners with no experience of the situations in which they are expected to perform. They know the theory but have no practical experience and are not able to make clinical decisions. This can lead to limited and inflexible performance as the novice has to follow the rules and is unable to deviate from them.

The novice cannot use intuition to make decisions because of the academic nature of their knowledge. Once the novice nurse reaches the advanced beginner stage they can give what Benner (1984) describes as "marginally acceptable performance" and begin to make basic decisions about small aspects of care. Although the advanced beginner has started to recognise patterns of care, she still needs help in priority setting. At the competent stage, the nurse begins to see actions in terms of long term goals and is able to prioritise.

She can make multiple decisions about immediate and appropriate care and has the ability to cope with clinical demands on her time and has become more efficient and organised. Proficient performers perceive a situation as a whole because they understand its meaning in terms of long term goals. They have the experience to recognise whole situations. Proficient nurses use guidelines but know that they can have significance at one time but may mean something entirely different in another situation. Proficient nurses, according to Benner (1984) are willing to take risks knowing that they will not lose control of the situation. Experts are described by Benner (1984) as being very intuitive.

They can deviate from the rules as it enables then to perform more quickly and proficiently. With experience and mastery, skills become transformed leading to a change in performance. If experts are asked to stick to the rules, their performance deteriorates. Comparing the Cognitive Continuum theory (Hamm 1988) with that of the Skills Acquisition theory (Benner 1984) shows some similarities but there is a difference in relation to intuitive reasoning. The Cognitive Continuum theory places intuition at the start of the decision making process whilst the skills acquisition theory sees it as the end point. In relating this point to decision making in a triage situation, I witnessed that most intuitive decisions came with experience and knowledge, which gave confidence to the triage nurse in making the decisions.

This would follow the skills acquisition theory as the triage nurse being a trained practitioner with a sound knowledge base, although a "novice" could use the use of the Manchester Triage System if she followed the rules. Triage originates from the French word trier, which means "to sort". Nurse triage priorities emergency patients into a system of care as part of an integral process. It was not until the 1980's that the concept of nurse triage became popular in the United Kingdom (Edwards 1999). The introduction of the Patients Charter (Department of Health 1991) requires all patients attending Accident units to be immediately assessed by a registered nurse. Budassi and Barber (1981) defined the role of triage as "the process of deciding the priorities for the therapeutic interventions of a given individual or individuals and the place where those interventions should occur".

Therefore, the main aim of the triage nurse is the early assessment of patients in order to determine the priority of care according to the individual's clinical need. Triage has other aspects too (Handyside 1996) it can help to make more efficient use of the departmental facilities as patients are allocated to the most appropriate clinical areas and regular reassessment of patients ensures the appropriateness of care can be modified if necessary. Control of infection may be initiated as soon as the patient has been assessed which in turn provides a safer environment for patient care. Patients and their relatives have an identifiable and approachable source of information for any enquiries that can help to reduce anxiety and so reduce aggression (Dolan 1998). Appropriate first aid measures can be implemented as soon as the patient is seen by the triage nurse and the triage nurse can offer verbal and written information immediately regarding health care. Nurse triage should be a rapid, superficial assessment taking no longer than a few minutes.

Its purpose is to elicit information from the patient in order to determine the complaint. Whilst in some cases this may be very straightforward, for example a patient presenting with a clear history of simple trauma to a limb, a large proportion of people attending the accident unit present with a more complex history involving various factors. These situations call on the skills of the triage nurse. The method of triage tries to provide the practitioner with a diagnosis and then with a clinical priority. (Manchester Triage Group 1998). The aim of the Manchester triage system is to help both clinical management of an individual patient and the management of the accident unit as a whole, this was found to be best achieved by accurate allocation of clinical priority.

The Manchester Triage System requires practitioners to select from a wide range of flow charts (Appendix 1) and to find a limited number of signs and symptoms at each level of clinical priority. The signs and symptoms that discriminate between the clinical priorities are called discriminators. (Appendix 3) The relationship between the clinical priority allocated and the clinical management that follows is easily confused. Clinical priority calls for adequate gathering of information to place the patient into one of the five categories defined in the National Triage Scale (Appendix 1). This may require a much deeper understanding of the needs of the patient and can be affected by many factors such as the time of day or night, the staffing levels on the unit and the number of beds available in the hospital. The Manchester Triage System uses a series of steps to reach a conclusion, and consists of three main phases, identification of a problem, determination of the alternatives and selection of the most appropriate alternative.

Adair (1999) described five steps to effective decision making: Define the objective; Collect relevant information; generate feasible options; Make the decision; implement and evaluate. These steps are very similar to the triage decision making process using the Manchester Triage System. Having assessed the patient, the triage nurse must make a decision. Symptom clustering is a method used to help determine the clinical needs of the patient.

Using existing knowledge and experience, the nurse can group together the presenting symptoms in order to identify the severity of the condition. In this way "chest pain" can be more readily associated with a cardiac condition if the symptom cluster includes nausea, shortness of breath, grey or clammy pallor, radiation of pain to the jaw or left arm, crushing type pain or a tight band across the chest. Conversely, a symptom cluster that includes increased pain on coughing and deep inspiration and a productive cough would be more indicative of a respiratory condition. (Rund and Rausch 1981). Clinical priority can change and triage must therefore be dynamic (Manchester Triage Group 1998). Using the Manchester Triage System, priorities can be carried out quickly and efficiently by appropriately trained staff.

It is therefore an extremely useful tool for re-evaluation of priorities that can be quickly acted upon where necessary. The effective and appropriate use of these assessment tools is dependant on the expertise and knowledge of the triage nurse. This is not simply based on the length of time the nurse has been doing the job but also her ability to understand and make use of decision making processes. Benners (1984) model of skill acquisition looks at the way in which expertise in a given area develops through an individual nurses experience. It is the expert nurse's use of experience and intuition when making decisions that differentiates her from the less experienced nurse. The professional judgement and clinical expertise along with the use of intuition are crucial to the decision making processes of triage.

The triage nurse must also ensure that her decisions are ethically sound (Handyside 1996 and Jones 1993). It has been suggested that if the triage groups are clear and unequivocal, the role of the triage nurse can be carried out by any nurse after minimum training (Burgess 1992). The presence of a series of signs and symptoms will warrant a particular priority through adherence to a written protocol in the form of flow charts, such as the Manchester triage system. While these systems standardise the response of the triage nurse their use has limitations (Rice and Abel 1993) and does not allow for the nurse to use either judgement or intuition (Rund and Rausch 1981), No assessment of the patient is required other than establishing a symptom and allocating a predetermined priority. A patient admitted to my placement area who was later diagnosed as suffering from a myocardial infarction did not give a clear history of crushing, left sided chest pain with radiation to the jaw or left shoulder. He simply complained of tingling in the fingers.

It required some skilful questioning to elicit any other appropriate history. The skill of the triage nurse lies in her intuition and the ability to ask discriminating questions which lead quickly to a triage decision. While this may be seen as a learned skill it must also be recognised that the ability to ask the "minimum of question with the maximum of value" (Rund and Rausch 1981) comes with experience. Triage nurses must possess the skill and competency to arrive at an accurate decision on the priority rating of the patient (Yates, 1989. Rock and Pledge 1991 and Dolan 1993). However, the increasing demand of their competency and accountability may impose feelings of inadequacy.

Rowe (1992) found that American nurses are not comfortable with triaging and as a result were found to be inconsistent in their triage decisions, mainly due to their inexperience and inadequate knowledge. The major component in triaging is communication, which allows the nurse to obtain specific history in order to make an accurate decision. Kelly (1994) states that communication skills are imperative for the triage nurse to convey concern and reassurance. However communication could also cause the nurses to feel uncomfortable during this process (Purnell 1993). Purnell (1991) and Buckles and Carew (1990) claim that triaging requires more knowledge than in the general area and should only be undertaken by competent practitioners. Dolan (1993) highlights that due to a lack of training, emergency nurses are often slow in recognising important details in the process of assessment.

Bailey, Hallam and Hurst (1987) state that a suitably educated first level nurse is needed to determine the seriousness of a patients' problems. This is advocated by Rowe (1992), who claims that novice triage nurses without appropriate training are unable to concentrate on the relevant aspects of patients' complaints. This would eventually hamper effective triage decision making. These suggestions were seen to be correct in the practice area. During the placement a registered nurse who had been in the department for six months was trained to triage.

Whilst training the nurse was supervised totally by a senior nurse and she appeared competent and confident, making prioritising decisions rapidly and accurately. However, when she was left alone to triage unsupervised, her decisions became less accurate and she showed a crisis of confidence in that she eventually had to leave the department in tears. Benner (1984) would attribute this action to the nurse in question still being at the novice stage of the skills acquisition theory, where the expectations of performance were above the nurses experience. Competent triage nurses who have much experience of the triage situation were seen not to consult the flow charts contained in the Manchester triage system handbook. They appeared to use their experience and intuition to prioritise patients.

Those less experienced nurses consulted the book often in order to make a decision, Thus demonstrating Benners (1984) skills acquisition level theory in that following guidelines does not allow for intuitive decision making. The role of the triage nurse is one of the most stressful in the accident unit (Bland 1988). The workload is variable and patients often arrive in pain and frightened. The role demands quick and safe decisions to be made. Colleagues working in other areas of the department rely upon the judgement of the triage nurse to prioritise effectively. If vital information is not picked up at the initial assessment, the result could be disastrous for the patient.

While the safety net of "over triage" can be used to make a difficult decision safe, the overuse of this practice can increase pressure on colleagues, delay treatment of other patients and undermine the effectiveness of the whole triage system. Poor communication due to language difficulties is not uncommon in the practice setting I attended. This factor can hinder the triage nurse in the initial assessment. The age and condition of the patient is also a contributory factor of the assessment.

If there is any doubt as to the condition, a higher priority is usually given. The ability to think critically is a fundamental principle in nursing practice. A nurse's ability to make relevant observations, to identify actual and potential problems of a patient and to intervene and prioritise care appropriately all demands decision making abilities (Tanner 1987). These responsibilities require triage nurses to justify their clinical decisions with evidence from clinical research and to be accountable for those decisions in the practice environment. The use of the Manchester Triage System in the practice are I attended is an example of an objective decision making tool. There are also local policies in place in addition to this tool.

For example, Local policy states that any child under the age of 12 years should be given a priority one step higher than that given by the Manchester Triage system. Whilst I feel that the decision making in triage was mainly objective, there were instances when subjective influences played a part in the decisions made. One such case was a young girl who was a persistent attender in the department for deliberate self harm. During my placement she was admitted eight times. Each time she had been drinking and harmed herself in various ways. Each time she was given a priority 4 category, which is standard waiting time.

The staff were very casual about her injuries and some staff seemed very short tempered with the girl. On each occasion after approximately two hours in the department, the girl just walked out, usually without any treatment. The decision to allocate her a standard waiting time category, I believe came more from the subjective influences of personal feelings and bias than the objective use of the triage system. The experienced staff knew that the patient would eventually leave without treatment and therefore were not prepared to waste time with her. At first, I felt this was not correct procedure, but after the girls 4th visit, which was a particularly busy shift, I too was resigned to the outcome of her attendance. Accountability is an integral part of professional practice.

In the course of practice judgements have to be made in a wide variety of circumstances. Professional accountability is concerned with weighing up the interests of patients in complex situations using professional knowledge, judgement and skills to make a decision and enabling nurses to account for the decision made (UKCC 1999). Clinical decision making frameworks and their application to triage practice have important implications for the autonomy of triage nurses. An assumption made about clinical decision making frameworks is that a better understanding of the theory will improve the quality of decisions made in practice.

The reported estimates of correctness associated with the final triage category found more experienced nurses held higher levels of correctness. (Tanner et al 1987). It is more reasonable to consider that more experienced nurses will have a greater sense of accuracy as they have had more exposure to triage assessments. Benner (1984) argues that this exposure provides the experiences which lead to expertise, therefore it can be expected that the more experienced nurse have greater expertise than the less experienced nurse.

It can be argued that such use of relevant past experiences in triage decision making can be advantageous to reaching a decision. Benner and Tanner (1987) described this as "similarity recognition" and attributed it to intuition, suggesting that intuitive judgements may be part of the triage decision making process. Benner (1984) believed that the phenomenological perspective is the most effective approach to decision making because it offers a more holistic view and in emergency situations practitioners can focus accurately on the problem without searching around for alternatives which would simply waste time. The constraints to effective decision making in triage that I witnessed were mainly down to staff shortages and bed shortages.

Although these did not actually affect the category of priority given, they did have a knock on effect for staff working in the department. However, I feel that all the triage trained nurses did their job effectively without prejudice. Patients were always kept well informed about waiting times, however I do feel that a leaflet explaining the priority system could be given to each individual rather than just the verbal information. This would enable the patient to feel informed and be a reference for when the waiting time was extended due to emergency admissions. Whilst studying triage and the decision making processes of the triage system, I have attempted to find a critical analysis of the Manchester Triage system. This has been wholly unsuccessful.

I can only assume that the system is such a successful implementation that no one has ever thought to undertake an evaluation of the use of it. In undertaking this investigation, I have discovered that whilst knowledge plays an enormous part in providing holistic nursing care, intuition based upon experience has a much bigger part in caring for patients from all perspectives. The nurse who can take just one look at a patient and know that there is a potential problem is usually widely experienced and very open minded. A sound knowledge base on which to base these judgements is crucial, but instinct and intuition can only come from experience.