How to keep the faith in triage?

classicdame, MSN, EdD · Jun 8, 2009

There is a lot of fear in triage. Fear that you will make a decision that allows them to wait longer, hurt more or not be taken seriously. You have to remember your therapeutic communication - you are talking to people who are a little bit crazy at the moment (or a whole lot of crazy!). Our hospital rotates the job of triage nurse as it can cause burn out quickly. It takes a special person to work there!

angel337, MSN, RN · Jun 8, 2009

its never good to be in triage everyday because you will become burned out. some people present differently in triage than they do once they get back to a room. some are more dramatic, some people do lie about s/s because they know if they say certain things it will bump up their acuity. but for every pt that does this there are many, many more that don't. as long as you keep in mind that most people have a good reason to be in the Ed it will make your triage experience better. always keep your critical thinking skills high and really look and listen to the pt. also i would suggest that you don't spend more than 4-5 hours in triage, this makes it more bearable.

LLLLiiiFFEsaveer · Jun 8, 2009

Triage...

I really enjoy my time in triage! Although, it is still very new to me. My place requires RN's to have a minimum of 2 years experience before they will send you out to greet the public. Triage RN's must also complete an educational requirement lasting 2 days (16 hours), and pass a departmental test involving all coordinators immitating real-life triage scenarios, etc.. Pretty stringent really, but for good reasons in my mind.

So, I have just recently had the opportunity... (Been a triage RN for only the last 5 months).

I can relate to the question in general though... The faith is kept alive for me through those people who need our help immediately, and get it! The rest can wait-period

Emergency means Emergency. It does not mean Fast... Trust in your training/experience - Trust in your partners training/experience (we have a point, and a comprehensive triage RN). Know that you did your best. What else can you do? I mean, you can only answer the same questions so many times... Assessment skills are vital here!

I have been fortunate with my family and friends soo far, but still... Know very well that no matter how well you think you know somebody, you honestly will never know what someone else is thinking/what their true motives really are, etc.. It's just the way people are... Nothing can be done about that!

Roy Fokker, BSN, RN · Jun 10, 2009

i usually enjoy triage. a couple of my colleagues say that i'm temperamentally suited for it too (no dilly-dalying. get to the point and fast...) a couple others say that i'm still too "young and naieve"

triage is not easy. priorotizing is the key. one of my triage-preceptors loved to play this exercise:

"you have two patients. patient a is a 45 year old complaining of chest pain all day. upon furthur examination, pt. is found to be mildly sob and states that his arms "feel funny". has a history of high cholesterol and is mildly overweight. vital signs are borderline - moderately elevated bp and hr. marked tachypnea.

patient b is a 90 year old with dyspnea on exertion and c/o "i don't feel like mtself. tired all the time". wheezing upon auscultation. has an extensive history including prior mis (with stents and caths), frequent utis, an old stroke with mild residual and cancer. vitals are borderline - a temp of 101 f, hr in the 100s but a stable bp.

now if you had just one bed left in the ed, which patient would you assign the bed to and which patient would you send back to the waiting room?"

so on and so forth...

her "q & a" sessions were absolutely brutal (never an easy answer!) - but she was also fair and impartial.

i learned tons from her (heck, i still am learning!)

in a perfect world, triage would be redundant.

however, as we do not live in a 'perfect world of infinite resources', your role as "triage nurse" is not to act as the "primary nurse" for the patient, but to decide "given the circumstances, who will potentially benefit the most from the limited resources available in the ed".

it is a concept that needs to be stressed at every opportunity.

how do i keep the faith?

1. stay focused. stay objective.

yes, it sounds "cold" and not very "compassionate" - but trust me, it'll help you keep your sanity in triage. losing objectivity while pursuing compassion will lead to disaster (this is true for most aspects of nursing but especially true for triage).

2. once i've triaged someone (and unless i send them back to the waiting room again), that patient is "out of sight, out of mind".

3. i try to keep my charge nurse in the loop as best as i can. having another set of eyes keep an eye on triaged patients helps (especially if they're sent back to the waiting room because all beds in the ed are occupied).

4. there would be cases at times when a nurse assigned to a certain pod suddenly has three open beds and three patients show up. you feel "guilty" about 'slamming your friend/colleague' with 3 new patients back-to-back.

but you must not shirk from it!

and this is really where a good charge nurse differentiates themselves from the average/mediocre ones - because they'll pitch in (start a line on one patient and do an ekg on another while the primary nurse assigned goes around with primary assessment and paperwork/labs etc.) as a triage nurse in such instances, i usually tarry for a minute or so to help change the patient into a gown, hand them a specimen cup with a cleansing towel and instructions on how to give a clean, mid-stream urine catch (if indicated) and hook them up to the bedside monitor (if i have time).

other than that, it often boils down to the individual personality and experience of each nurse. some nurses struggle with triage, some nurses excel at it. the vast majority of us fall somewhere in the middle.

i must also say that the practice of 'rotating staff' through different spots helps - if nothing else, at least to give folks a break from doing the same 'routine' and getting into a rut. it also helps refresh memory and competency.

cheers,

cookienay · Jun 10, 2009

It is a hard job being the gatekeeper to hell...

As the previous poster said- remain objective. don't allow the cesspool of humanity to cloud your decion-making. some people are reasonable, others are not. some are patient, others- not so much. some people are sick, some may be dying. Even though someone may truly be sick does not mean they will not have to wait for care. you can only do what you can do. I remember on the worst triage day of my life, my director came out to triage and told us "i know people are waiting a long time today- just don't let anybody die in the lobby. keep up the good work." That is all you can do.

Another piece of advice if I may... if you are the primary triage RN- make sure you make every patient come to the window, or you go to them. none of this getting signed in by a family member. if you are sick enough to come to the ER, you are sick enough to tell the triage nurse about your troubles. I almost had to learn this the hard way. Momma signs in her 37 y.o. son for "diarrhea". When I look up and see him leaned over the security desk gray and ashen obviously, there was alot more than diarrhea going on. the following respiratory arrest verified my hunch. BUt I digress...

Best wishes to you in triage. It can be a scary place, sometimes!!

LLLLiiiFFEsaveer · Jun 15, 2009

i usually enjoy triage. a couple of my colleagues say that i'm temperamentally suited for it too (no dilly-dalying. get to the point and fast...) a couple others say that i'm still too "young and naieve"
triage is not easy. priorotizing is the key. one of my triage-preceptors loved to play this exercise:
"you have two patients. patient a is a 45 year old complaining of chest pain all day. upon furthur examination, pt. is found to be mildly sob and states that his arms "feel funny". has a history of high cholesterol and is mildly overweight. vital signs are borderline - moderately elevated bp and hr. marked tachypnea.
patient b is a 90 year old with dyspnea on exertion and c/o "i don't feel like mtself. tired all the time". wheezing upon auscultation. has an extensive history including prior mis (with stents and caths), frequent utis, an old stroke with mild residual and cancer. vitals are borderline - a temp of 101 f, hr in the 100s but a stable bp.
now if you had just one bed left in the ed, which patient would you assign the bed to and which patient would you send back to the waiting room?"
so on and so forth...
her "q & a" sessions were absolutely brutal (never an easy answer!) - but she was also fair and impartial.
i learned tons from her (heck, i still am learning!)
in a perfect world, triage would be redundant.
however, as we do not live in a 'perfect world of infinite resources', your role as "triage nurse" is not to act as the "primary nurse" for the patient, but to decide "given the circumstances, who will potentially benefit the most from the limited resources available in the ed".
it is a concept that needs to be stressed at every opportunity.
how do i keep the faith?
1. stay focused. stay objective.
yes, it sounds "cold" and not very "compassionate" - but trust me, it'll help you keep your sanity in triage. losing objectivity while pursuing compassion will lead to disaster (this is true for most aspects of nursing but especially true for triage).
2. once i've triaged someone (and unless i send them back to the waiting room again), that patient is "out of sight, out of mind".
3. i try to keep my charge nurse in the loop as best as i can. having another set of eyes keep an eye on triaged patients helps (especially if they're sent back to the waiting room because all beds in the ed are occupied).
4. there would be cases at times when a nurse assigned to a certain pod suddenly has three open beds and three patients show up. you feel "guilty" about 'slamming your friend/colleague' with 3 new patients back-to-back.
but you must not shirk from it!
and this is really where a good charge nurse differentiates themselves from the average/mediocre ones - because they'll pitch in (start a line on one patient and do an ekg on another while the primary nurse assigned goes around with primary assessment and paperwork/labs etc.) as a triage nurse in such instances, i usually tarry for a minute or so to help change the patient into a gown, hand them a specimen cup with a cleansing towel and instructions on how to give a clean, mid-stream urine catch (if indicated) and hook them up to the bedside monitor (if i have time).
other than that, it often boils down to the individual personality and experience of each nurse. some nurses struggle with triage, some nurses excel at it. the vast majority of us fall somewhere in the middle.
i must also say that the practice of 'rotating staff' through different spots helps - if nothing else, at least to give folks a break from doing the same 'routine' and getting into a rut. it also helps refresh memory and competency.
cheers,

yeahhhh!!hhh!,

cheerszz...

not one part of that post do i dissagree with, that is.. without re-reading.

thankx!

2BSure · Jun 15, 2009

Hey all
I find that I have been in triage a lot recently in the big inner city ER where I work. How do you all manage to keep the faith in people? I have always been known for my patience and caring, but recently I have been feeling less compassionate and a little angry. It's like trying to put your finger in a leaking dam holding back a tide of humanity. When people lie to you and swear, and give drama and attitude it's hard to not judge people. Its hard to give every new person a fresh chance and not let your previous tough triage callous your heart.
I truly care about people and am very patient, but it is hard sometimes. I would like to hear some other peoples thoughts on this.
Thanks

I really understand. I walk in and the waiting room is bulging and it is still bulging when I walk out. I have insisted on a rotation for triage but I don't know an ER that doesn't.

Footballnut · Jul 9, 2009

I just try to remember that people who show up in the ED are under stress and their emotions are going to be heightened for their visit, starting at the triage desk. I don't take it personally. Oh, and I still have faith in people, just not in all people. Perhaps my years of sorting time has sharpened my BS meter!