Beyond guidelines: discretionary practice in face‐to‐face triage nursing

Abstract

This article draws on ethnographic data from a Norwegian emergency primary care clinic (EPCC) to explore nurses' discretionary application of guidelines. Specifically, it analyses nurses' discretionary use of the Manchester Triage System (MTS) when performing face-to-face triage, that is, assessing the urgency of patients' complaints. The analysis shows how nurses assessed patients at odds with MTS prescriptions by collecting supplementary data, engaging in differential diagnostic and holistic reasoning, relying on emotion and intuition, and allowing colleagues and patients to influence their reasoning. The findings also show how nurses' reasoning led them to override guidelines both overtly and covertly. Based on this evidence, it is argued that nurses' assessments relied more on internalised 'triage mindlines' than on codified triage guidelines, although the MTS did function as a support system, checklist and system for supervisory control. The study complements existing research on standardisation in nursing by providing an in-depth analysis of nurses' methods for navigating guidelines and by detailing how deviations from those guidelines spring from their clinical reasoning. The challenges of imposing a managerial logic on professional labour are also highlighted, which is of particular relevance in light of the drive towards standardisation in modern healthcare.

Health effects of direct triaging to physiotherapists in primary care for patients with musculoskeletal disorders: a pragmatic randomized controlled trial

“…Nurse ability to triage efficiently has been demonstrated earlier in primary care, 6 as has their ability to use professional judgement in combination with structured guidelines in order to plan relevant care for each patient. 8 Most of the patients in the physiotherapist group were shown to have better health outcomes over time, which supports the conclusion that nurses have the competence to discern between appropriate and inappropriate patients for direct triaging to physiotherapists.…”

Negotiated Discretion: Redressing the Neglect of Negotiation in “Street‐Level Bureaucracy”

“…To judge eligibility, the nurses performed more thorough clinical assessments than those recommended by the MTS, taking account of additional signs, symptoms and risk factors (see Johannessen ). However, more than “purely” clinical factors were at play; as is typical of street‐level bureaucrats, the nurses drew on a range of commonsense heuristics when judging the credibility of patients' complaints.…”

“…We saw Caroline deploying this when she told the coughing man “today, when there's so much to do, we only take cases that cannot wait. You're welcome to wait if you want, but it will be a long wait.” Closely related, nurses often added an appeal to the objectivity of their triage guidelines, as when Nurse Theresa told a patient “You don't have anything critical I can upgrade you on today.” Her use of can suggests that “upgrades” were beyond her control and thus nonnegotiable (a white lie, as nurses frequently used discretion to adjust a patient's triage code; see Johannessen ). Given the typically crowded state of the clinic, this was often observed to be an effective approach; it was also comfortable for nurses, as it allowed them to blame a third party (guidelines or the crowded state of the EPCC) without having to take personal responsibility for seeking to deny access.…”

A perception survey on the roles of nurses during triage in a selected public hospital in Kwazulu-Natal Province, South Africa

“…However, triage can either be front lined by nurses or physicians. The role of nurses during triage is critical, especially when nurses are at frontline [ 9 ]. Another study concurs that placing nurses at frontline during triage is indeed a critical and crucial role, especially on battle fields or war [ 10 ].…”