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

Area of Science:

• Nursing Practice and Healthcare Management
• Clinical Decision-Making and Patient Assessment

Background:

• Growing emphasis on standardisation in nursing care.
• Need to understand how nurses apply guidelines in real-world settings.
• Exploration of the discretionary space within codified protocols.

Purpose of the Study:

• To explore nurses' discretionary application of guidelines in emergency primary care.
• To analyse the use of the Manchester Triage System (MTS) in face-to-face patient triage.
• To understand the factors influencing nurses' deviation from triage guidelines.

Main Methods:

• Ethnographic data collection from a Norwegian emergency primary care clinic (EPCC).
• Analysis of nurses' face-to-face triage assessments and decision-making processes.
• Examination of how nurses navigate and potentially override the Manchester Triage System (MTS).

Main Results:

• Nurses assessed patient urgency differently from MTS prescriptions by gathering extra data and using holistic reasoning.
• Factors influencing assessments included emotion, intuition, colleague input, and patient influence.
• Nurses overtly and covertly overrode guidelines, relying on internalized 'triage mindlines' over codified protocols.

Conclusions:

• Nurses' clinical reasoning and internalized 'triage mindlines' significantly influence patient assessment, often diverging from standardized guidelines.
• The Manchester Triage System (MTS) served as a support, checklist, and control mechanism rather than a rigid directive.
• Highlights challenges in applying managerial logic to professional nursing labor amidst healthcare standardization efforts.