Change management and buy-in from stakeholders will be crucial for successful implementation of nurse-led triage. Getting physicians, administrators, nurses and other staff on board and supportive of the transition to this new model will require effective communication of how it will benefit patients and the organization. Physicians may be resistant to ceding some of their traditional decision-making authority over patient care. It will need to be demonstrated that advanced practice nurses and NPs have the clinical expertise and competency to conduct triage safely. Administrators will need to see it can help maximize staff utilization and potentially reduce wait times and left without being seen rates. Nurses taking on this new role may feel anxious about expanding their scope of practice. Comprehensive training programs and leadership support will be important to gain confidence and buy-in.
Sufficient nursing resources and the ability to flex staffing patterns to meet fluctuating demand will also pose a challenge. Nurse-led triage requires nursing FTEs be dedicated to conducting medical screening exams, ordering tests, and determining the proper treatment stream or disposition rather than splitting time between multiple tasks. Having backup nurses available during peak volumes or implementation will ensure triage can still be performed timely when volume temporarily exceeds staffed positions. Tools to accurately forecast patient volumes and develop flexible staffing schedules will need to be utilized. Organizations with nursing shortages or inflexible scheduling may struggle to consistently meet these resource needs.
Ensuring the competency and ongoing development of nurses and NPs transitioning or newly hired into triage roles will take ongoing investment. Advanced assessment and diagnostic reasoning skills differ from general floor nursing. Formal didactic and clinical training programs will need to be developed and/or augmented with competency validation. Opportunities for continued education and skills practice must also be provided. Without maintaining a high level of competency it can compromise patient safety and outcomes if the wrong dispositions are made. Role expansion may also increase nurse turnover if adequate training and career ladder opportunities are not available.
Workflow redesign and upgrades to technologies like the EHR will be needed to fully support nurse-led triage. Existing paper or basic electronic systems may need reconfiguring to capture the level of documentation and decision making required in triage. Order sets, protocols, and determinant tools may need building/customizing. Changes to how patients physically flow through the department may also be needed. Without the proper tools and workflows in place, triage nurses could become frustrated and inefficient. Delays treating the right patients in the right areas and duplicative testing could negate purported benefits.
Legal and regulatory issues surrounding the scopes of RN and NP practice will need to be thoroughly evaluated and addressed on a state by state basis. While most nursing programs train to an advanced level, state boards set the scope parameters and some may prohibit independent decision making. Organizations would likely need to engage in discussions with these regulatory bodies to gain comfort that aspects of triage like selecting treatment streams fall within legal scopes. Medical malpractice insurers may also need to vet coverage of nurses in these expanded roles. Without resolved legal and regulatory clarity up front, implementation timelines could face delays or need to be scaled back in certain locations.
Cost is another potential barrier depending on factors like the need for capital equipment, renovations, training programs, additional staffing, and information system modifications. A business case would need to evaluate both the hard costs of implementation and ongoing operations against projected utilization, revenue generation from increased volumes, reduction in wait times, and other quality improvements. The payback period may stretch beyond standard capital allocation timeframes in some environments depending on the baseline utilization and financials. Without a clear return on investment demonstrated, gaining administrative and financial approval could prove difficult especially if competing against other strategic priorities with perhaps faster paybacks.
Change management, sufficient resources, competency development, workflow and technology optimization, legal and regulatory alignment, and a strong financial case will all need thorough planning and mitigation to reduce barriers to successful nurse-led triage adoption. A phased, multi-year approach may smooth the transition by piloting in certain areas, upskilling staff gradually, and incrementally expanding the model. Leadership support, cross-functional participation, and ongoing evaluation will also help address issues that arise proactively rather than letting them become insurmountable roadblocks. With diligent preparation to overcome these challenges, nurse-led triage has great potential to provide higher quality, more efficient care delivery.