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Decision making by Telephone Triage Nurses

Pattern Recognition and Estimation of Symptom Urgency

Recent research on decisionmaking has implications for clinical decision making in telephone triage, CDSS, clinical call center policies, and industry regulations — worker fatigue, understaffing, over scheduling.

Thinking Critically about Critical Thinking

“In the beginner’s mind there are many possibilities. In the expert’s mind there are few.”   Shunryu Suzuki

Whether you call it critical thinking, intuition, or pattern recognition, it is the core activity of telephone triage. In telehealth, the current wisdom is that with a few essential elements — guidelines or protocols, adequate numbers of qualified, trained clinicians, and standards —  clinicians will make good decisions. Some facilities have such essentials, however, many still do not.  However, the question remains: Are these system components of sufficient quality to support high-quality critical thinking?  If expert systems that clinicians currently use are safe, why is error and delay in care still so prevalent?

Currently, there are few published studies describing accepted criteria for quality in telehealth training, computerized decision support systems (CDSS) also known as guidelines, or job qualifications. However, even without evidence-based  standards, it seems unlikely that one can achieve good decisions with inferior resources. Questioning common assumptions about protocols and telepractice, we can shed light on the next steps needed.

When it comes to decision making, expert systems are the bottom line. If this premise is true, then the qualifications of the decision maker is secondary.  For years, the controversy (i.e., protocols as decision making vs. decision support tools) has gone unresolved. The danger of this assumption is that clinical decision makers begin to appear irrelevant, the next step being to simply replace clinicians with non-clinicians.

Protocols facilitate improved decision making. If protocols are well designed, they do facilitate good decisions. However, one expert (Klein) suggests that  over relying on information technology carries the risk of transforming clinicians from active decision-makers into passive ‘system operators”.  To suggest that protocols may actually interfere at times with critical thinking may seem heretical.  More research is needed on who can safely perform telephone triage — clinicians or non-clincians.  Outcomes measures such as referral rates — “right referral” and “under referral” —  are needed, with the goal of improved, user friendly, intuitive designs.

Experienced clinicians eliminate the need for protocols.  While there are studies describing adequate levels of decision making without the aid of protocols, guidelines are and always will be essential to telephone triage, prompting questions and providing information that we once knew, but may have forgotten. In hi-tech systems, CDSS function as the ‘workhorse’ through report generation, necessary for ongoing correction and improvement of decision support systems.  A more interesting question might be  ‘How do clinicians make decisions, and how can we create expert systems that “make it easy to do the right thing” (IOM)?’

Any experienced clinician can perform telephone triage. As researchers on decision making point out, human beings tolerate ambiguity differently. And uncertainty affects the ability to make decisions, by adding more stress. While all clinical situations involve a certain degree of uncertainty, telephone triage is the ultimate uncertainty. Some clinicians cannot make the transition from face to face to telephone encounters. In the future, managers may use psychological testing to screen prospective staff for ‘ambiguity tolerance’, thereby selecting the best and most stress-resilient decision-makers.

Controversy and questioning assumptions are a natural part of the growth and development of this emerging subspecialty. By facing these issues head-on, we can avoid medical error, strengthen our professionalism, and serve our patients and facilities better. Think about it, critically.

Critical Thinking in Telehealth

Telephone triage involves decision making under conditions of uncertainty and urgency. It also requires open-ended questions to estimate symptom urgency, rule out urgency, and the ability to clinically interpret patients’ responses to questions.  The task is made more complex by conflicting goals (call volume quotas vs. quality patient/nurse interactions), ‘noise’ (irrelevant data and histories). Clinicians must consider context (age, gender, past medical history, etc.), focus on what is ‘salient’ (meaningful bits of information), and identify patterns to form “working diagnoses” – all within minutes, repeated many times each shift. Telephone triage is considered a high-stress, high-stakes clinical activity because it is fast-paced and may involve a heavy workload and urgent situations.

Here are links to several experts, and their evidence about decision-making:

Malcolm Gladwell  Blink is a book about how we think without thinking, about choices made in the blink of an eye, that actually aren’t as simple as they seem. Why do some people follow their instincts and win, while others end up stumbling into error?  Blink reveals that great decision makers aren’t those who process the most information or spend the most time deliberating, but those who have perfected the art of “thin-slicing”– filtering the very few factors that matter from an overwhelming number of variables.

  • Reduce complex problems to simplest elements. Editing helps decision-making
  • Too much information paralyzes the unconscious. Keep it simple
  • Good decision making =  balance of conscious and instinctive thinking

Roy Baumeister  

  • Decision Fatigue = Shorter Shifts?
  • Brain Fuel = Better snacks. “No Glucose, No Willpower” (to make good decisions repeatedly)
  •  Do You Suffer from Decision Fatigue?
  • From Will Power: “The idea for the experiment arose when a researcher was choosing a suit for his wedding, and began going through the choices of fabric, lining material and buttons. ‘By the time I got through the third pile of fabric swatches I wanted to kill myself”,  Levav recalls.  ‘After a while my only response to the tailor became: What do you recommend? I just couldn’t take it'”.

Gary Klein

  • Detect problems through emotional cues —  that “gut feeling” one gets when something isn’t right.
  •  Maintain an active stance — if something doesn’t make sense, it acts as an alarm, not to be dismissed.
  • Beware of organizational barriers — rigid procedures or institutionalized inertia.
  • Reframe situations;  consult with colleagues to review a situation with fresh eyes.

Rosalinda Alfaro-Le Fevre 

  • Reduce stereotyping and inflexibility for improved clinical decision making
  • Eliminate barriers to intuition (anxiety, stress, fatigue, rushing, feeling judged and environmental distractions).

Research Articles 

Nurse telephone triage in Dutch out-of-hours primary care: the relation between history taking and urgency estimation. Huibers L, Giesen P, Smits M, Mokkink H, Grol R, Wensing M.  Eur J Emerg Med. 2012 Oct;19(5):309-15. doi: 10.1097/MEJ.0b013e32834d3e67.

Science and intuition: do both have a place in clinical decision making?   Pearson H.  Br J Nurs. 2013 Feb 28-Mar 13;22(4):212-5.

Nursing intuition: a valid form of knowledge. Green C. Nurs Philos. 2012 Apr;13(2):98-111. doi: 10.1111/j.1466-769X.2011.00507.x.

Nursing experience and preference for intuition in decision making.Pretz JE, Folse VN. J Clin Nurs. 2011 Oct;20(19-20):2878-89. doi: 10.1111/j.1365-2702.2011.03705.x. Epub 2011 May 18.

Used with the permission of Sheila Wheeler and TeleTriage Systems


Written by Sheila Wheeler (15 Posts)

SHEILA WHEELER, RN, MS, is acknowledged as an international expert in the field of telephone triage. She has practiced nursing for over 30 years, primarily in critical care, emergency department and clinic settings. An accomplished writer, educator, researcher and consultant, Ms. Wheeler is currently President of TeleTriage Systems in San Anselmo, California.