Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20

The Role of Patients’ Stories in Emergency Medicine Triage Lori. A. Roscoe, Eric M. Eisenberg & Colin Forde To cite this article: Lori. A. Roscoe, Eric M. Eisenberg & Colin Forde (2016): The Role of Patients’ Stories in Emergency Medicine Triage, Health Communication, DOI: 10.1080/10410236.2015.1046020 To link to this article: http://dx.doi.org/10.1080/10410236.2015.1046020

Published online: 16 Feb 2016.

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HEALTH COMMUNICATION http://dx.doi.org/10.1080/10410236.2015.1046020

The Role of Patients’ Stories in Emergency Medicine Triage Lori. A. Roscoea, Eric M. Eisenberg,a and Colin Fordea a

Department of Communication, University of South Florida

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ABSTRACT

Emergency medicine is a communicative activity, and characteristics such as incomplete information, time pressure, and the potentially serious consequences of errors complicate effective communication and decision making. The present study examined the triage process as an interpretive activity driven in part by the patient’s story. Of four identified communication processes in the emergency department (ED), the “handoff” of patients between shifts has been identified as especially problematic since missing contextual details from patients’ stories increased the probability of errors. The problematic nature of patient handoffs led to our interest in triage, the initial site of interpretation and decision making. Triage distinguishes patients with emergent medical conditions requiring immediate care from those who can more safely wait for medical attention. We report results from 110 hours of observing the triage process and semistructured interviews with 16 triage nurses in a Level I Trauma Center in an urban teaching hospital in the southeastern United States. Field notes and interview transcripts were analyzed and coded to explore decision rules and information sources used in triage decision making. Triage nurses generally discounted patients’ stories in favor of information from visual cues and vital signs. Patients’ stories tended to influence the triage process only in certain cases when the story contained information that was not readily apparent, such as a recent organ transplant. Triage nurses’ reliance on “gut feeling,” however, might be a kind of narrative sense-making that combines observable and measurable clinical facts with the narrative competence to utilize intuition and past experience.

Emergency departments (EDs) are unique contexts in which to study communication and decision making. Incomplete or conflicting information, multiple and competing goals, intense time pressures, and the potentially serious consequences of errors characterize the ED work environment (Eppich, Brannen, & Hunt, 2008). Emergency medicine is a largely communicative process, and the four routine communication processes in emergency medicine—triage, testing and evaluation, handoffs, and admitting—are “sites of reality construction and negotiation” crucial in determining the direction and quality of patient care (Eisenberg et al., 2005, p. 397). In each of these processes, information and interpretations about the severity of the patient’s condition and the appropriate course of clinical action are developed and shared. Eisenberg and colleagues (2005) examined shift changes in the ED, and found that the probability of patient safety errors increased when contextual details from patients’ stories were not shared. The problematic nature of patients’ stories during handoffs in emergency medicine led to our interest in examining how patients’ stories are interpreted and acted upon in the initial site of patient care in the ED—triage. This study examined the triage process to determine the decision rules and information sources triage nurses rely on to determine the severity of a patient’s medical condition, and specifically to understand the role of the patient’s story as an information source.

CONTACT Lori A. Roscoe © 2016 Taylor & Francis

[email protected]

The ED communication environment The work environment of a typical ED is fundamentally different from other health care contexts (Wears et al., 2003). Work in EDs is unbounded, as there is little control over the workload; staff shortages, limited resources, overcrowding, and long wait times for patients often result (Derlet, Richards, & Kravitz, 2001; Trzeciak & Rivers, 2003). Numerous patients with highly variable complaints must be cared for simultaneously (Wears et al., 2003). EDs in the United States serve an expanding and diverse patient population, including insured patients whose primary care physicians send them to the ED for evaluation and treatment on weekends, holidays, or after office hours; patients with mental health and substance abuse issues who are not able to receive treatment in their communities; and uninsured patients, for whom the ED is often the only care available. The ED represents both “the primary gateway for acute care and the source of health care of last resort” (Nelson, Venkat, & Davenport, 2014, p. 75). EDs also carry out forensic work in health care and treat the victims and perpetrators of crimes, as well as those affected by natural and man-made disasters. The need to dramatically shift and reset one’s cognitive frame and communicative approach is further complicated by constant interruptions and changing priorities. As new

University of South Florida, 4202 East Fowler Avenue, Tampa, FL 33620.

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patients arrive and the conditions of patients who are waiting change, as beds become available, and as shift changes occur, the hierarchy of which patients require the most urgent care is in constant flux. ED work is also characterized by a high level of uncertainty, and errors in judgment on the part of health care professionals can have serious consequences (Schenkel, 2000; Wears et al., 2003). There is often a lack of background information on patients, and difficult decisions must sometimes be made before critical laboratory data or other test results are available. Emergency medical care is provided under significant time constraints, which can cause a narrowing of focus and a rush to make decisions, with little privacy and few backstage areas in which in-depth discussions could potentially occur. ED staff members receive little or no feedback on the results of their care, making it difficult to learn from experience, and there is little opportunity for practice (Wears et al., 2003). Most work in the ED is routine and the riskiest procedures and decisions arise only sporadically, much like other high-risk occupations like air traffic control and anesthesiology (Eisenberg et al., 2005). EDs are chaotic and emotional. Kelly (2005) describes everyone in the ED as afraid: Staff members are scared of making mistakes or missing something serious, and patients are afraid of the trauma or symptoms they are experiencing or that they will not receive timely or proper care. In our experience, ED staff members are not so much afraid as they are aware of and concerned about the consequences of their decisions and actions and the possibility for serious errors.

ED communication processes The work environment of the ED makes the specific communication processes that occur—triage, testing and evaluation, handoffs, and admitting—susceptible to error and medical mistakes that can harm patients (Eisenberg et al., 2005). Handoffs—either at shift changes, between paramedics and ED staff, or between ED staff and admitting physicians—may be particularly vulnerable, and several studies have examined their problematic nature. Handoffs during shift changes may be particularly vulnerable (Cheung et al., 2010). Eisenberg et al. (2005) found that when important details of patients’ stories were not repeated during ED shift changes, the probability of patient safety errors increased. Maughan, Lei, and Cydulka (2011) observed 110 handoff sessions encompassing 992 patients. Examination handoff errors were noted in 13% of handoffs, and omissions were noted in 45% of handoffs. ED physicians and hospitalists have differing expectations about handoffs, but agree that insufficient information, incomplete data, omissions and faulty information flow contributed to ambiguity that could negatively impact patient outcomes (Apker, Mallak, & Gibson, 2007). In a simulated emergency situation, quantitative information requiring frequent updates and information generated early were most likely to be inaccurate (Bogenstatter et al., 2009). Meta-analyses (Bost, Crilly, Wallis, Patterson, & Chaboyer, 2010; Calleja, Aitken, & Cooke, 2011) reveal that structured handovers that involved both written and oral communication improved information exchange. Handoff communication assessment tools further

clarify areas for improvement, including shared understanding of the handoff process and accurate information transfer (Apker et al., 2010; Manser, Foster, Gisin, Jaeckel, & Ummenhofer, 2010).

Rationale for present study The problematic nature of patients’ stories during handoffs in emergency medicine led to our interest in how patients’ stories are interpreted and acted upon during triage, the initial site of interaction in the ED. The main goal of triage is to distinguish patients with emergent medical conditions requiring immediate care from patients who can more safely wait for medical attention. The triage process occurs as patients arrive at the front desk or ambulance bay, and is the first time the patient’s story is elicited and evaluated as a source of credible information (Edwards & Sines, 2008). Triage professionals typically ask patients “What brings you to the emergency department today?” or something similar. Most patients arrive in the ED with a story that recounts the series of events that led up to their arrival—that is, to form connections among their actions and consequences, and to come to grips with changing circumstances (Mattingly, 1998). Some patients, however, arrive in the ED unable to tell their story due to accidents, traumas, unconsciousness, dementia, or psychiatric illnesses, which further complicates the triage process. When one asks triage nurses how they determine which patients require immediate medical care, the standard answer is “experience,” or “gut feeling,” which makes it difficult to understand or improve the process, much less train triage professionals to take on this important role. This study examined the triage process to determine the decision rules and information sources triage nurses rely on to determine the severity of a patient’s medical condition, and specifically to clarify the role of the patient’s story as a source of information. We posed the following research questions: RQ1: What decision rules and information sources are most pertinent to the triage process? RQ2: What is the role of the patient’s story in guiding triage decisions?

Theoretical framework The study of narrative is receiving increased attention in health communication theory, research, and practice (Bochner, 2002; Carbaugh, 2001; Harter, Japp, & Beck, 2008; Langellier & Peterson, 2004). Clinical interactions have a narrative structure, and patients and health care providers construct their own understandings of their experiences and then use those interpretive frames to guide their actions (Sharf, Harter, Yamasaki, & Haidet, 2011). The narrative medicine paradigm in particular calls attention to medicine as a narrative practice, and patients and their bodies as vehicles for stories; medicine that is practiced with an appreciation for narrative competence allows health care practitioners to recognize, absorb, interpret, be moved by, and act on stories

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of illness (Charon, 2006). Patients work to emplot the series of events in which they find themselves; that is, they work to form connections between actions and consequences, their agency and that of others, and the changing circumstances and emerging storylines (Mattingly, 1998). Personal stories, however, do not often align well with the norms and expectations of health care organizations. The stories patients tell in emergency departments and other clinical settings are interpreted from within the grand narrative of medicine as a biomedical enterprise (Harter et al., 2008), which seeks to reduce disease to biological mechanisms of cause and effect that can be efficiently diagnosed and effectively treated through science and technology. As Sharf states, “The natural inclination of the patient is to present a sequence of events, rather than the chief complaint or problem list in which the doctor is interested” (1990, p. 222). Browning’s (1992) conceptualization of lists and stories as forms of organizational communication provides a useful theoretical framework to explain how narratives and scientific/technical information might influence one another in clinical settings. Browning (1992) described how narrative rationality (here, the patient’s story) is generally subjugated to technical rationality in organizational contexts (actionable lists developed by emergency medical professionals), and that there is a constant interplay between these two forms of rationality. Patients (or their representatives) come to the ED with a personal story, and a main goal of triage is to translate the story into an actionable list to guide clinical decisionmaking. Decisions are made, treatments are administered, or patients are admitted for further testing and evaluation, and upon their release from the hospital or ED, the patient again seeks a story that answers the question, “What just happened to me and what does it mean?” By their very nature, personal stories are not composed only of relevant facts, nor do they conform to categories that might readily suggest unequivocal clinical actions. Rather, patients’ stories might contain a broad range of information, rich detail, and potentially irrelevant contextual factors that must be sorted through to make the determination about which patients require emergency care. “Stories are communications about personal experiences told in everyday discourse,” (Browning, 1992, p. 285); they unfold chronologically rather than strategically, and are flexible, evolving, and partial. Some patients present with a “good story” that is comprised of symptoms and complaints that can be readily translated into clinical actions; for example, patients complaining of shortness of breath who have a history of asthma are clear candidates for a protocol that includes nebulizer treatment and inhaled steroids. Patients with vague complaints suggesting multiple underlying causes (fever, headache, abdominal distress) complicate this translation process. Too many possible diagnoses are involved, some of which require immediate action and some of which are likely to resolve with only sufficient time. In all cases, this translation process from patient’s story to actionable list is vulnerable due to the relative lack of background data on patients, heavy workload, and other conditions that make it difficult to take the needed time for interpretation.

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Lists, by contrast, are technical communications, and their legitimacy is based on the belief that technique or a series of specific steps will lead to identifiable and predictable outcomes. The list is “an already made up mind” of extrahistorical and universal content, which implies “an already existing answer” to questions (Cooper & Burrell, 1988, p. 94). A community of practice, such as triage nurses in an ED, authorizes the use of particular lists in the pursuit of particular goals. For a triage nurse, the sooner a patient’s story can be translated into a clinical list, the sooner the patient can receive needed care, which can preserve human lives, organizational reputations, and scarce medical resources.

Influence of technology Another complicating factor in the translation process from story to list is technology. As of 2010, nearly half of hospital EDs in the United States used some kind of electronic medical records system (Geisler, Schuur, & Pallin, 2010). While these systems provide ready access to patient medical histories and test results, they also further reify the list and technical rationality as preeminent. Most electronic medical records streamline data entry by using drop-down boxes that direct the user to the “most applicable” screens. A patient whose story neatly conforms to the logic of the electronic “list” may be recorded more accurately and be perceived as having “a good story.” Extraneous details and contextual information either may not be recorded or may be consigned to a note box or tab that is not central to the main medical record. Another complicating factor in triage is the rigidity with which lists are maintained once this initial translation process takes place. Most EDs use the Emergency Severity Index (ESI) or similar numerical ranking of patient acuity such as the Canadian Triage and Acuity Scale (CTAS) (Atak, Rankin, & Then, 2005). Reducing a complex set of complaints into a numerical category can create a false sense of certainty, which can lead to reluctance to revisit or revise an initial diagnosis. Attachment to an ill-formed initial impression can make it harder to hear and respond to new information, increasing the likelihood of an adverse event. Less experienced ED physicians tend to rely more heavily on objective data, use linear thinking to move to a diagnosis quickly, and discount data that did not “fit” their initial conceptual framework (Schubert, Denmark, Crandall, Gnome, & Pappas, 2013). Failure to acknowledge ambiguity and uncertainty introduced by certain elements of the patient’s story can lead to inaccuracies and errors. In most EDs, and in particular at our study site, nurses are responsible for triage. The decisions made by triage nurses set in motion a set of tests and procedures to confirm the initial diagnosis with vital signs and other laboratory data. Often difficult decisions with potentially serious consequences must be made before crucial information can be obtained; said another way, triage nurses are called upon to act definitively even when they are unsure about the best course of action. Observing the triage process provides an opportunity to study the translation of patients’ stories into lists of clinical actions, in real time (Eisenberg, Baglia, & Pynes, 2006).

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Methods We employed ethnographic observations of triage nurses and patients and semistructured interviews with triage nurses to explore our research questions. Qualitative methods such as these are preferred when the goal is to examine how people interpret the meaning of the information they are soliciting and acting upon.

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Study Site and Participants The study site was a Level I trauma center located in a large, urban, not-for-profit teaching hospital in the southeastern United States, legally mandated to treat all patients who enter, regardless of insurance status or ability to pay. Level I trauma centers are equipped to treat the most critically injured and acutely ill patients 24 hours a day, 365 days a year. This ED covered approximately 65,000 square feet, and contained 66 private rooms for adult, pediatric, minor emergency, chest pain, stroke, and psychiatric patients. Up to 250 patients could be treated simultaneously, and nearly 100,000 patients were treated in the year prior to our study. Participants were the 16 triage nurses employed in the ED at the study facility. Ten were female and six male; seven were Caucasian, six African-American, and three Hispanic. All but one identified their credentials as registered nurse; one was a licensed practical nurse. These nurses had an average of 10 years of professional nursing experience, ranging from 2 to 22 years.

before or after the nurse’s shift, and lasted between 30 and 60 minutes. Interview questions consisted of general questions about the goals of triage, how they approached the triage process, training for triage, and examples of when it was easy or difficult to complete the triage process. Interviews were audio-recorded and transcribed. Research team members independently reviewed and coded all data from combined field notes and interview transcripts. Each researcher developed his or her own coding scheme to capture data relevant to the research questions that guided the study. Once independent coding was completed, we met as a research team and developed a common coding scheme that consisted of both a priori codes and emergent codes (Denzin & Lincoln, 2008). We collapsed a priori codes into broad categories that captured the decision rules and information sources used by triage nurses in decision making, in particular the ways in which patients’ stories were solicited, regarded, interpreted, and acted upon. Each research team member independently recoded the data using the common coding scheme, and then team members met to collectively resolve the few discrepancies that arose in interpretation and categorization. We identified theoretical concepts that emerged from the process of constantly comparing the data to existing codes and thematic categories to create a conceptual story line, or theory, that helped explain decision rules used in triage and clarified the role of the patient’s story. We then met with the charge nurses who supervised the triage process and with the ED administration at the study facility to confirm that our coding scheme and preliminary analyses of the data corresponded to their experience.

Data Collection and Analysis The study received approval from the University of South Florida Institutional Review Board, and informed consent was obtained from all triage nurses who were interviewed and from all triage nurse supervisors for observations. Patients were asked verbally for permission to observe their interactions with triage nurses. Our research team consisted of a white male professor, a white female professor, a white female graduate research assistant, and an African American male graduate research assistant. We report the results of 110 hours of observing interactions between triage nurses and patients. Every shift and every day of the week was observed over a 4-month period: 6:00 a.m.–12:00 noon, 27 hours of observation; 12:00 noon– 6:00 p.m., 36 hours of observation; 6:00 p.m. to midnight, 45 hours of observation; and midnight to 2:00 a.m., 2 hours of observation. Research team members observed the triage process either beside the triage nurse assigned to the “pivot desk,” which is the first place patients came when entering the ED from private transportation; alongside the triage nurse assigned to the “com (communication) desk,” which is the entry point for patients arriving by ambulance; or in the small triage examination rooms where patients were interviewed and initially examined. Research team members manually recorded field notes during their observations. Semistructured interviews were conducted by one member of the research team (CF) with all 16 triage nurses. Interviews were conducted in a private room adjacent to the ED either

Results The primary focus of this study was to begin to clarify the decision rules and information sources most pertinent to the triage process, and the role the patient’s story plays in triage nurses’ decision making. Analysis of the data from field notes and interviews allowed us to develop a model of the triage decision-making process (see Figure 1). The model posits three sources of information used in triage: visual (observations of the patient’s appearance and behavior), vital (information from initial clinical tests like temperature and blood pressure), and verbal (the patient’s story of the reason for their visit to the ED). Nurses relied most on visual data, and cited decision rules such as “If the patient is pink, warm, and dry, they can wait for treatment.” This was not a racially biased reference to skin color, but a more general rule comparing a patient’s skin tone and color to what it might be normally. For example, one nurse said, “Their color, you know, if they are gray, if they’re pale, you just know something is going on.” Another rule emphasized the need to keep patients who arrived walking or standing (i.e., vertical) vertical, rather than allowing them to lie down; this might have been partly a response to a sizable number of homeless patients who arrived in the ED hoping to find a clean bed but not in need of emergency medical care. Visual cues also included how easy or difficult it was for the patient to walk to the pivot desk and complete a short questionnaire consisting of a few basic questions (name,

HEALTH COMMUNICATION

Verbal Information: The patient’s story of the reason for their visit to the ED

Visual Cues: Observations of the patient’s appearance and behavior

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Triage Process

Vital Signs: Information from initial clinical tests (e.g., temperature and blood pressure)

Figure 1. Influences on the triage decision-making process.

medical issue, allergies). The content of their answers was less important than the ease with which the patient could navigate the form. For example, if a patient could competently and quickly complete the form, and then declared he or she was dizzy or experiencing a high level of pain, the patient’s narrative was more likely to be discounted. In other cases, patients who insisted they were “fine,” and only in the ED because their spouse insisted, but who could not easily write their name on the form were seen as having a more urgent need for care. Nurses also identified a particular category of visual impressions that signaled a need for immediate clinical attention. One nurse referred to things such as skin pallor, labored breathing, difficulty in walking unassisted, or the inability to answer simple questions as “oh [expletive] signs.” One said, “Sometimes you don’t even have to pick up a stethoscope to hear rattling in their lungs, the effort of their breathing, if they’re diaphoretic, these are what we call the ‘Oh [expletive] signs.’” Part of the routine triage process was to collect vital signs such as pulse, pulse oximetry, blood pressure, and temperature, which were used to confirm initial visual impressions of the patient’s condition. The Role of the Patient’s Story in Triage Contrary to our expectations as communication scholars and the results of previous studies (Eisenberg et al., 2005; Wears et al., 2003), the patient’s story was generally not seen by nurses as a reliable or important source of data. Triage nurses said things such as “patients lie, vitals don’t” and reported that patients’ stories often “got in the way” or required so much interpretation and redirection as to be nearly useless. Nurses reported that patients tended to want to start their stories in the distant past and the triage nurse’s goal was to bring them into the present, to determine what happened most recently that prompted this visit to the ED. Triage nurses talked about wanting patients to “get to the meat and potatoes of why they

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are standing in front of me at this moment.” An often-used phrase was “but what happened today that brought you to the Emergency Room?” Differences in punctuation, or the appropriate beginning and ending of a narrative (Watzlawick, Beavin, & Jackson, 1967), signal another potential impediment to the translation of patients’ stories to actionable lists of clinical tasks. Punctuation is an important factor in how individuals perceive and attach meaning to their communication experiences. Individuals punctuate their experiences from their own point of view, and “disagreement about how to punctuate the sequence of events is at the root of countless relationship struggles” (Watzlawick et al., 1967, p. 56). While this concept has been most often applied to family or other interpersonal relationships, it also applies to the interactions between ED patients and triage nurses. Time is a precious commodity to a triage nurse in a busy ED, and the need to identify a chief complaint and move the patient another step along the process as efficiently as possible is essential. Patients, on the other hand, have been waiting, sometimes for quite a while, to be seen by a clinician and to tell their story. The patient may see causality where none exists, or may include information that is not helpful or relevant. Moreover, individuals tend to punctuate events in such a way as to appear to be the hero or heroine of their story, and thus may be inclined to leave out information that is relevant to the triage process but may be unflattering or embarrassing. Such information as missed doses of medication, addiction or mental health issues, or failure to adhere to treatment recommendations may be withheld. One nurse said, “Patients never tell you the whole story.” External factors, such as overcrowding in the waiting room, also influence how triage nurses listen to patients’ stories. One nurse said: If there are a lot of people in the waiting room and we are backed up I will triage faster and have a tendency to cut people off. I’m like I don’t need to hear the whole story, I just need you to give me exactly why you came to the hospital today! Sometimes they get upset, they want to tell you the whole story, but I don’t have 25 minutes, I have 3–5 minutes and another 10 patients to take care of. I’m just not there to listen to them all day.

The patient’s story (verbal) was almost always discounted in favor of the information provided by the nurse’s own observations (visual). Even when nurses were listening to the patient’s story, they were simultaneously observing their visual presentation: You always listen to your patients, they know their bodies best. But at the same time, when you’re listening to them you’re watching them, you’re watching how they’re breathing, you’re watching if they seem guarded, you’re watching if they’re grunting, you’re watching if they’re anxious and you try to note those things along with what they’re telling you.

Another nurse said: I try to do a combination of things at one time—I’ll get their vital signs as I’m talking to them because I want to have a comprehensive story, a good clinical picture about why they’re here in the ED without getting muddled into their past medical history and what happened in 1971.

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Interestingly, the electronic medical records system in use in this ED also played a role in relegating the patient’s story to a supporting role. As one nurse described, “Our medical records system doesn’t let you miss anything. These patients go on and on and on and you have to learn to separate what you need to enter into the computer from the other stuff that isn’t important.” There were several instances in which the patient’s verbal description of the situation conflicted with the nurse’s initial observations, and in these situations, the patient’s story had even less credibility. Some patients were very dramatic in their expressions of pain or discomfort, but their physical presentation belied the presence of any significant pain. For example, one patient approached the pivot desk screaming in pain, saying, “God! oh my god, oh my god! I’m hurting so much, I’m hurting so much!” but was able to easily complete the initial paperwork and was walking without assistance; the patient was directed to the waiting room. Other patients’ stories underestimated the seriousness of their medical condition and were also discounted. In the following situation, the patient asserted nothing much was wrong, but the triage nurse’s observations indicated something else entirely: I had a patient who, as he walked up to me, I thought, “here comes an MI” [myocardial infarction]. He was gray, he looked awful, and he was holding his jaw and said he had an infected tooth. I woke up the doctor on call and said “hey I’ve got a tooth pain out here” and he said he would be up in a while. Meanwhile the patient looks like crap and he kept taking deep breaths, and his wife looked at him with way more concern than you would for a toothache. I put him on the monitor and when the doctor came down, he looked at me like why are you doing this for tooth pain? And sure enough, two minutes later he coded.

Such cases in which the patient’s story contradicted the nurse’s impressions, in either direction, affected the credibility and utility of the patients’ stories, and in many cases led to the story being dismissed altogether. Patients were sometimes complicit in downgrading the value of what they offered verbally in favor of acting in ways they believed would result in quicker medical care. One nurse recounted a situation in which a fortyish-year-old woman arrived by ambulance, accompanied by her large, Latin family. The nurse said: She was moaning and screaming and appeared somewhat mentally altered, but the way she was acting didn’t match any specific diagnosis, just a lot of drama. So our first instinct was that this was nonsense. One thing we do with uncooperative patients without a specific diagnosis is send them for a CT scan. I’ll be damned if she didn’t come back with a head bleed!

The nurse walked back to the patient and her family and told them in Spanish, “Hey missus, you are killing us here, we’re going to treat you, we’ve done a CT scan and we know something is wrong. Can you please calm down so we can give you appropriate care?” The patient calmed down immediately and said, “I hurt so bad but I didn’t think you would believe me if I just told you how I felt.” In this case the patient’s dramatic actions impeded access to care; if she had come in and said “I have the worst headache in my life” the nurse would have ordered the CT scan immediately. The nurse said, “We would have gotten the CT scan sooner and

with less difficulty if we had had some kind of story to work with, rather than all the drama between the patient and her family.” Similar to the characteristics referred to previously as “oh [expletive] signs,” there were certain verbal descriptions in patients’ stories that elevated the patient’s narration as a crucial source of information. One nurse called this the “well that changes everything” comment. Verbal descriptions of things such as bleeding or pain in early pregnancy, previous organ transplants, serious infections like HIV/AIDS, or the existence of unusual comorbid conditions that are not easily determined visually elevated the patient’s story to the most important information source. For example, a patient with abdominal pain might be evaluated as able to wait safely for medical attention, but a patient whose story included the fact that the pain radiated to their back (a symptom of a possible aortic dissection), would receive immediate evaluation. Less experienced triage nurses might not ask about radiating pain, and would likely be reassured by the patient’s normal blood pressure measurement; this would be even more likely if the patient’s story included something like he had been working in the yard the day before and had possibly strained some muscles. If, however, a more experienced nurse asked about radiating pain and took a blood pressure measurement in both arms (and overlooked the detail about working in the yard) the patient’s acuity rating would be raised and the possibility of a dissecting aneurysm would be immediately explored. Another patient, a woman who appeared to be in her late 50s, approached the pivot desk accompanied by her husband. The woman said they had arrived in the area late last night after a long overseas flight, and she woke up not feeling very good, with vague complaints of fatigue and light-headedness. She came to the ED because they were getting on a cruise ship later in the afternoon and wanted to be sure she was well enough for the trip. The triage nurse determined from these details that the woman might be anxious about the cruise, or the victim of a short-term virus, and directed the patient and her husband to the waiting room. As they turned around, the husband said, “Don’t you want to tell them about your liver transplant last month?,” which changed everything. In these cases, triage nurses looked to the patient’s story to provide a baseline (“I’ve never felt this way”), to establish a clinically significant precipitating event (“I was gardening, and then I felt this tearing feeling in my chest, and I started to sweat”), or to provide a critical clinical fact not discernable through observation alone (previous organ transplant). Such comments triggered more immediate action and greater attention to the patient’s story. Except in these special cases, our results indicated the patient’s story about what brought him or her to the ED was discounted by triage nurses in favor of the information provided by the nurse’s own visual observations and the objective data provided by vital signs and other clinical measurements. Both clinical observations and vital signs are components of the technical rationality that guides most clinical action. The patient’s story—the source of narrative rationality—provided crucial clinical data only when the

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patient’s story included certain key words and phrases (pregnancy, chest pain, organ transplant) that changed or triggered specific clinical actions, some of which (chest pain) some patients had learned to manipulate in an attempt to influence the perceived urgency of their medical care needs.

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Discussion The purpose of the present study was to extend Eisenberg and colleagues’ (2005) findings about the importance of the patient’s story in handoffs between shifts in the ED to the triage process. Inattention to passing along the patient’s story when care was transferred to a new nurse during shift changes greatly increased the chances of medical errors. Our initial expectations were that patients’ stories would also be crucial in informing the critical decisions triage nurses routinely make. Our findings, however, revealed that triage nurses relied on a combination of visual observations and the measurement of patients’ vital signs to make initial determinations of patients’ acuity more so than the information contained in patients’ stories. The patient’s story was not routinely viewed as a reliable or important source of information. Nurses tended to rely on the patient’s story only when it included a key phrase such as “previous organ transplant” that would change the initial diagnosis and evaluation of patient acuity in a way that was not easily observable or immediately apparent through the measurement of vital signs. There are several possible explanations. First, effective communication in the ED is defined more by efficiency than comprehensiveness, and by a preference for what appears to be clear or relevant from a clinical as opposed to a patient perspective (Dean & Oetzel, 2014). As in other organizational settings, technical rationality is preferred over narrative rationality (Browning, 1992; Eisenberg et al., 2005). The focus in triage is on making accurate decisions as quickly as possible, using one’s clinical judgment, past experience, and whatever objective data are available, without becoming distracted by irrelevant details. Second, the reliance on visual impressions and vital signs rather than the patient’s story may result from triage nurses having to learn to be comfortable and confident about making clinical decisions and taking appropriate action in situations where the patient has no story. Trauma patients, patients with cognitive dysfunction or severe psychiatric symptoms, and patients with language barriers are often encountered in the ED, often without friends or family, making any attempt to elicit and use a patient’s story futile. Third, triage nurses quickly learn how to identify patient stories that are attempts to get attention, obtain drugs, or even find a comfortable place to lie down for a while, none of which are appropriate uses of scarce ED resources. Triage nurses are aware that the severity ratings they assign to patients are correlated with resource use; time and money are valuable resources in the ED, just as they are in all work environments. The triage nurses we observed and interviewed acted and reported feeling as though their judgment of a patient’s level

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of severity was a personal responsibility and potentially a matter of life and death. Nurses said things such as “I don’t want a bad outcome on my conscience,” “A good shift is when no one dies because of me,” and “You know nurses . . . well, it’s a personal job to them and they take it very seriously.” During handoffs, missing elements of the patient’s story could lead to patient safety errors (Eisenberg et al., 2005), but in the triage process, overreliance on the patient’s story might lead to mistakes in judgments about patient acuity. During the handoff and triage processes, narrative rationality is subjugated to technical rationality, but with differing outcomes and potential for errors. Triage nurses also emphasized the role that their own “gut feeling” or intuition about patients played in their ability to make accurate determinations of patient acuity. Despite its scientific basis, clinical success ultimately depends on a provider’s interpretive capacities to make clinical judgments, especially in uncertain and contingent moments (Sharf et al., 2011). Triage nurses might be constructing their own narratives about their patients that combine scientific/technical facts as well as the narrative sense-making ability that privileges their intuition and past experience. Perhaps the grand narrative of medicine as a scientific enterprise with its own particular “values and beliefs; hierarchy of characters; past, present, and future; sacred spaces; goals and purposes; manners and means” (Harter et al., 2008, p. 22) discourages nurses from openly describing how their decisions depend on narrative sense-making. They may be hesitant to state outright that an information source as “soft” as a story might be important, or they might lack confidence in their abilities to interpret stories given their scientific training. Difficulties arise, however, when the singularities of a patient’s case are juxtaposed with the generalities of a “science-using practice” like emergency medicine (Sharf et al., 2011, p. 40). Efficiency, prized in emergency medicine, is enhanced when the same solution or set of steps can be effectively applied to all patients in a similar category, rather than individualizing care for a particular person. “With regard to health and illness, the concern with meaning exemplified by a narrative approach is perhaps best understood in contrast to the concern with so-called facts associated with the logicoscientific approach to reasoning that has pervaded modern medical practice” (Babrow, Kline, & Rawlins, 2008, p. 33). Comparing narrative- and evidence-based medicine, Greenhalgh (1998) explained: “Conventional medical training teaches students to view medicine as a science and the doctor as an impartial investigator who builds differential diagnoses like scientific theories and excludes competing possibilities in a manner akin to the falsification of hypotheses” (p. 248). Rather than a deductive approach that seeks general laws of human behavior, an inductive narrative approach privileges the particularities of individual lives and attempts to understand how specific persons in particular times and circumstances describe their experiences. Narrative medicine (Charon, 2006) is a paradigm that seeks to balance the need for efficiency, evidence-based decision making, and scientific facts that can be generalized across patients with an appreciation for the uniqueness and specific needs of each

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individual. Patients come to medical encounters with stories of their experiences; doctors (and triage nurses) are trained to act on lists of indicated clinical actions. The narrative medicine paradigm suggests that learning to interpret stories may help in understanding and improving the translation process from stories to lists. Perhaps triage nurses could be trained to reconcile visual clues, clinical measures, and the patient’s story so they could competently absorb, recognize, interpret, comprehend, and value all that patients (and their bodies) tell. Techniques such as close reading of patients’ narratives and writing exercises that encourage self-reflection have been used successfully to begin to develop narrative competence with various medical specialties (Roscoe, 2012) and would likely yield interesting results with groups of triage nurses. Our results contribute to continuing work in narrative medicine that goes beyond the verbal story to include the patient’s body itself as a kind of text (Charon, 2009). According to Charon, “Patients tell of themselves in all the ways they can, with words, gestures, silences, facial expressions, biopsies of their livers, tracings of their hearts” (p. 120). If health professionals can learn to listen to what the person says and to what the body says, they can translate the body’s news to the person who lives in it (Charon, 2009), which is potentially helpful in a number of ways. Medical encounters that include both the body and the person of the patient can help educate patients, enhance trust between doctors and patients, and assist the patient in returning to life outside of the illness with a story about what happened to him or her and what it means. When life and death hang in the balance and time is of utmost importance, as in emergency medicine, some of the competencies called for in the narrative medicine paradigm may not be realistic. While all clinical interactions possess some elements of narrative structure, some clinical moments are more likely to make room for and give more credence to the patient’s story. In the primary care setting, where physicians and patients are more likely to be involved in a longer term relationship, information about a patient’s emotional state, life events, and health behaviors might emerge over time and be useful in making treatment decisions and promoting overall wellness. An acute care context like an ED calls for a more reductionist approach focused on emergent symptoms outside the normal context of a patient’s life. Our results show this to be the case, as triage nurses sought only the context they needed to make an initial determination and actively avoided distracting accounts that they perceived as unnecessary or misleading. Nonetheless, even this interpretive strategy can be understood as having a certain narrative logic. The consistent references to gut feel and intuition are their own kind of narrative expression, one that captures implicit stories about how patients talk and act from the nurse’s perspective. In this sense, narrative competence may still play a role in effective triage decision making.

information sources and decision rules that triage nurses used to make determinations about patient acuity, and revealed that the patient’s story is often discounted in favor of visual information and vital signs, which nurses found more informative and more trustworthy. Generally speaking, in triage narrative rationality is subjugated to technical rationality. The nurses’ description of relying on intuition and gut feeling, however, may be euphemisms for reliance, at least in part, on what might be called narrative competencies. The results of this study begin to clarify how triage nurses make crucial decisions that impact patient safety, satisfaction, and outcomes. Future studies should attempt to extend these findings to EDs that differ in size, service level, and geographical area. We identified particular situations in which the importance of the story was elevated, and future research should develop a more precise inventory of the words and phrases that trigger closer attention to the patient’s story. These results also suggest the benefits that might accrue if we broadened our definition of the patient’s story to include the nonverbal factors that were so important in assessing acuity. As revealed here, the nurses appeared to learn more about the patient’s condition from how patients told their stories, rather than from any information the stories contained. Hospital administrators increasingly see the ED as a critical site for quality improvement. Strategies include the introduction of emergency medicine residencies, classification and analysis of patient safety errors and “near misses,” focusing on communication skills, and improving data/documentation systems (Francis, Spies, & Kerner, 2008). Other strategies involve team training to improve interprofessional communication and staff satisfaction (Cameron, Engel, McCarthy, & Buckley et al., 2010; Turner, 2012). As these and other approaches to cost containment, quality improvement, and throughput efficiencies in the ED are explored, “front-end” operations such as triage become an important area of focus. Various interventions have been proposed, including immediate bed placement for patients, dedicated “fast track” service lines, tracking systems, and self-service kiosk check-in (Stover-Baker, Stahlman, & Pollack, 2012; Wiler et al., 2010). The results of this study demonstrate that while some of these interventions might decrease patient waiting times in the ED, they might also interfere with an important visual source of information that improves the quality of triage decision making. An acknowledgment of the narrative structure of clinical encounters, including those in the ED, and an investment in narrative competence training for triage nurses may also be a worthwhile endeavor.

Acknowledgments The authors acknowledge the contributions of Meagan Araujo to the work presented here.

Conclusions and future research The results of this study provide a thick description of the triage process in a busy urban ED. Based on observations and interviews, we developed a model that highlights the

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