Passing the audition – the appraisal of client credibility and assessment by nurses at triage

Aim. This paper presents the findings of one aspect of a larger study aiming to build a substantive grounded theory of the process of initial assessment at triage. Background. Prioritisation at triage within emergency departments centres primarily on assessing the threat to physiological function of people presenting with health-care problems. This approach presumes that clinical reasoning strategies reside exclusively within the health-care practitioner, with the patient playing no active part in the process. Design. A grounded theory/symbolic interactionist methodology. Methods. Thirty-eight recordings were made of live triage encounters involving 14 emergency nurses from two demographically distinct emergency departments. At the end of the relevant shift, those encounters in which the nurses were involved were replayed to them. The recording was stopped after each question or comment by the nurse who was then asked to say what they were thinking at the time. The nurses’ thoughts were recorded, transcribed and analysed using the constant comparative method, in which hypotheses are generated and continually modified in the light of incoming data until a conceptual story line, or theory, is produced. Results. The findings suggest that the outward clinical signs of problems presenting to the emergency department were not viewed by nurses as neutral manifestations of the pathology itself but as a conscious or unconscious portrayal of patients’ physical discomfort and their perception of the nature of the problem. The way in which patients and carers depict their problems is used by triage nurses to determine the credibility of the clinical information they provide. Conclusion. Triage can be regarded as a process in which nurses act as an adjudicating panel, judging the clinical data before them through the appraisal of the way patients act out their problems and narrate their stories. Relevance to clinical practice. Nursing practice and research need to account for the patient’s contribution to the decision making process at triage