Applying Good Judgment to Telephone Triage Calls

By Cliff Hurst

As a call center consultant, my clients frequently ask me to help them clarify performance expectations. I help them to decide how to evaluate performance in various jobs. When we discuss this, I often have found it helpful to conduct the following thought experiment with them. I challenge clients with the question “Can we describe the essence of this job in just one word?”

For some jobs, this is easy. A teacher’s core function is to teach. A salesperson’s core function is to persuade. The core function of a carpenter’s helper may be to nail. However, for many jobs, this exercise is more difficult. What is the core function of a manager? Of a dental assistant? Even when no answer is forthcoming, the exercise itself tends to sharpen our focus.

In the fall of 2009, I was asked to give the closing presentation to the National Telehealth Conference, sponsored by Children’s Physicians Network. As I attended other educational sessions during the conference, I began to wonder if I could put into one word the core function of a telephone triage nurse. I realized that word is judgment.

The core function of a telephone triage nurse is to make good judgments. The job requires a nurse to make a rapid judgment based purely on verbal descriptions of symptoms described by the caller, whether to phone a doctor in the middle of the night, advise the patient to call an ambulance, go to the emergency room, or wait until the next day. It’s a demanding job. The risk of bad judgment is high; there are consequences. It is serious.

In telephone triage, there are three kinds of evaluative judgment that come into play. Let’s consider the little known theory in philosophy called formal axiology. “Axiology” stems from two Greek root words, “axia” and “logia.”  Axia means “value” and logia means “logic.”  Therefore, formal axiology is simply the study of the logic of value. Knowledge of axiology reveals to us the structure by which we make value judgments.

In formal axiology, there are three types of value and valuation. They are called the systemic (S), the extrinsic (E), and the intrinsic (I) dimensions. All three dimensions come into play in many situations in our lives that call for judgment in decision-making. Nowhere do they show up more clearly than they do in telephone triage.

Medical conditions can have complex symptoms. Moreover, a nurse has to make judgments as to the nature and severity of a patient’s condition based solely on the caller’s verbal descriptions. Unlike their counterparts in doctors’ offices, telenurses can’t see the patient. To help ease their task of evaluation, a number of protocols have been established. These protocols give the telenurse a set of guidelines to follow. Whenever possible, they take the format of a decision-tree. The guidelines consist of questions to ask of the caller and the answers that guide the nurse to the correct action to take.

The Systemic Dimension

A great deal of thought goes into designing the right series of questions to ask callers. Protocols intentionally reduce a complex valuational challenge to the simplest possible systemic dimension of yes/no. In fact, this makes a good axiological definition of the S realm of valuation. It is one that can be categorized by yes/no, on/off, either/or, or black/white. Systemic valuation leaves no room for in-between; it permits no shades of gray.

Naturally, not every medical circumstance can be reduced by protocols to a yes/no decision. However, a surprising number of them can. Without protocols to follow, the telehealth industry as we know it today could not exist. The job would simply be too hard. At the National Telehealth Conference, perhaps two-thirds of all of the presentations were devoted to this sort of systemic protocol. That’s how important the systemic dimension of judgment is.

The Extrinsic Dimension

However, good judgment cannot always be reduced to a yes or no question; not all decisions are choices between black/white. Sometimes a nurse must make distinctions among shades of gray. Take stomach pains, for instance. Let’s suppose that the presence of stomach pain, itself, is not a determining factor in deciding which actions to recommend to the patient. Rather, the intensity of the stomach pain is more important, or its duration, or perhaps a more precise location of the pain.

In these cases, the nurse’s job is to ferret out from the patient enough insight to be able to make a much more complex judgment call. Protocols for these conditions may instruct the nurse to ask, “How long has it been hurting?”  “Is the pain getting worse or is it subsiding?”  “On a scale of 1 to 10, how bad is it?”

When a judgment depends on these “shades of gray” valuations, we have moved to the extrinsic level of valuation. These are more complex judgments, and it is more difficult to discern the best decision to make.

During the convention, presentations involving extrinsic levels of evaluation took longer, were more nuanced in their recommendations, and they generated more questions and livelier discussion from participants. They revealed the large amount of irreducible complexity involved in a triage nurse’s job. Such topics accounted for perhaps one-third of all of the presentations during this conference.

The Intrinsic Dimension

If two-thirds of these conference presentations dealt with systemic judgment and one-third dealt with extrinsic judgment, then you may already be asking, “What about the third dimension?”  The fact is that one of the three dimensions of valuation, the intrinsic dimension, was virtually unaddressed from the front of the room. However, it was very much on the minds of triage nurses in attendance. I know this because discussions about the intrinsic dimension dominated informal conversations at every break, luncheon, breakfast, and social gathering.

In the language of formal axiology, the intrinsic dimension relates to that sort of valuation that deals with the incomparable. It deals with human emotions, such as fear and hope. It deals with relationship issues, such as trust. It is the most complex of the three dimensions.

Axiologists say that the I dimension is the richest in value. The I dimension arises when a mother with a sick child calls in the middle of the night, hoping she can find someone to talk to, hoping that there is someone out there who cares, someone who can tell her that it is not because she’s a bad mother that her child won’t stop crying and can’t sleep. Responding in the I dimension requires empathy on the part of the triage nurse. It requires caring; it means listening to the emotion behind the symptoms.

One of the nurses in attendance told me, “Whenever I take a call, the first thing I ask myself is: ‘Is this a question, or is it a cry [for help]?’  And I respond accordingly.”

I speculate that very often it is the degree of caring, the expression of empathy, the ability to listen supportively, which matters most in this line of work. In the caller’s mind, it’s often this personal element that defines the quality of healthcare they receive. I know from talking with hundreds of nurses that this is why they entered the profession to begin with, to create a space for this sort of helping bond with patients. Intrinsic valuation is one determinant of customer satisfaction within the telehealth industry. It is also the wellspring of job satisfaction for every nurse I have known.

Unfortunately, intrinsic valuation was virtually unaddressed in the conference agenda. There is no protocol for how to make a caller feel cared for. Perhaps no one is going to be sued for failing to do a good job with intrinsic evaluation. But, it does matter.

To honor the I dimension requires mindfulness. You must remain aware of its importance as a complement to the other two dimensions. It also takes time – a few seconds here, several minutes there. On some calls, it may even throw your average talk time out of standard for a week. As a result, we’re unlikely to find many telehealth centers whose key performance metrics make it easy for a nurse to provide intrinsic care. However, we should find ways to make room for it.


I hope that this description of the three levels of value and valuation has shed new light on this often-overlooked aspect of telehealth care. I hope it evokes a new level of dialogue, a new focus of training, and a new subject of conference topics, with CEU credit earned, for attending to the intrinsic dimension of care.

When we can put into proper balance all three levels of valuation, the S, the E, and the I, then we will have telephone nurses who are encouraged, empowered, and honored for addressing callers’ needs at all three levels in proportions appropriate to each circumstance and the needs of each caller.

Cliff Hurst is the founder and owner of Career Impact. As an organization development consultant, he has worked with call center clients across the U.S. and internationally for more than twenty years. He is the author of three books, numerous articles, and is a frequent speaker at industry conferences. He is currently a PhD student who is writing a dissertation on judgment and decision-making.

[From the June/July 2010 issue of AnswerStat magazine]