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April 3, 2019

By: Lynn Sayre Visser MSN, PHN, RN, CEN, CPEN

The do’s and don’ts of triage orientation

Three months out of nursing school I was assigned to orient to the triage nurse role in a fast-paced urban emergency department (ED). Patients and their support systems lined the hallways and overflowed out the door of the small waiting room. A large glass window separated me from the incoming patients standing shoulder to shoulder in the cramped hallway. On one hand, I loved that I could see each person as they entered the facility. I could assess from a distance things like breathing and skin color and whether they could walk unassisted or with the use of a medical device. Sometimes I could quickly identify who needed immediate help, while other times the person’s chief complaint was all a mystery until I had the time to talk to him or her.

My triage orientation consisted of a see one, do one, teach one approach. Watch a triage, perform a triage, and soon precept another new nurse to triage! Almost 25 years have passed, and I’m hopeful that this approach is now a thing of the past in triage orientation.

There is something to say about “ignorance is bliss”. Being a new nurse, green as could be, I didn’t understand the liability I faced each and every day I threw on my scrubs and eagerly marched into work. I didn’t appreciate how much each and every decision I made could have a potentially life-changing outcome for the individuals who stood before me. As the years passed and I gained experience, I found that the see one, do one, teach one philosophy was far from adequate to introduce a nurse to the triage setting. I came to realize that triage was actually one of the most litigious areas of the ED. Those split-second decisions I made over and over throughout the day had potentially significant consequences. I could change a person’s life for the better if I immediately recognized an acute stroke or myocardial infarction, or I could have a profound impact on a child’s life if I failed to recognize the signs and symptoms of child abuse.

No matter what your role, whether you’re the new orientee or the preceptor responsible for helping the orientee navigate their new position, a solid orientation is critical. In Chapter 1 of Fast Facts for the Triage Nurse 2ndEd., I offer insight into the purpose of triage orientation.

PURPOSE OF TRIAGE ORIENTATION

A thorough orientation to triage provides the foundational skills to build upon in the months and years ahead. The orientation should be designed to prepare a person for success and serves many purposes that include:

Understanding the Triage Role

  • Gaining confidence in the triage role
  • Decreasing stress by developing an understanding of the triage nurse role
  • Acquiring tips for enhancing productivity at triage
  • Improving job satisfaction

Advancing Current Knowledge

  • Developing strong customer service techniques to utilize at triage
  • Gaining awareness about compassion fatigue and empathy burnout
  • Managing families and their reactions to stress
  • Understanding how cultural beliefs and language barriers impact the delivery of care
  • Developing competency and improving patient care outcomes
  • Learning how to initiate advanced triage protocols

Understanding Triage Flow

  • Prioritizing an influx of patients in a short time frame
  • Learning when to perform a rapid triage assessment versus a comprehensive triage assessment
  • Understanding patient flow, acuity assignment, and priority setting
  • Learning how to work with a physician, physician assistant, or nurse practitioner at triage

Identifying “Red Flag” Patient Presentations and Enhancing Documentation Skills

  • Gaining awareness of high-acuity presentations and concerning red flag findings
  • Learning how to best document chief complaints and associated symptoms
  • Acquiring tips on working with the electronic medical record (EMR)
  • Developing skills to keep patients and staff safe

Understanding Policies and Procedures

  • Understanding legal concerns (e.g., provisions of the Emergency Medical Treatment and Active Labor Act [EMTALA]and Health Insurance Portability and Accountability Act [HIPAA] in order to decrease liability)
  • Gaining knowledge in the medical screening exam (MSE)
  • Understanding facility policies, procedures, and resource availability
  • Availability of a labor and delivery department, cardiac catheterization lab, trauma team, etc.

TRIAGE ORIENTATION

In preparing for triage orientation, the orientee may or may not have an opportunity to choose who shows him or her the ins and outs of triage. Nursing leadership or educators should be actively involved in carefully selecting triage preceptors. The preceptors chosen should be role model staff members who are passionate about teaching and who meet the recommended triage qualifications. From the time we are children, our parents, teachers, coaches, friends, and family share their wisdom, shaping us into the individuals we become. Nursing is the same in that our practice is strongly influenced by other nursing professionals. The right preceptor can make all the difference in a person’s orientation and future success at triage.

The many intricacies of triage take time to understand. Growing knowledge, understanding triage flow, identification of “red flag” patient presentations, and understanding policies and procedures are just a few of the essential elements of a solid triage orientation. Patients are sicker than ever, and there is no longer room for the see one, do one, teach one approach; you need to protect the patient, your license, and the facility where you are employed.

Reproduced with permission from Springer Publishing Company from Fast Facts for the Triage Nurse (2ndEd.). New York, NY: Springer Publishing.

 

Lynn Sayre Visser is the author of Fast Facts for the Triage Nurse (2ndEd.) and Rapid Access Guide for Triage and Emergency Nurses.  She has devoted her career to emergency nursing, triage education, and mentoring others.

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