Australasian Emergency Nursing Journal (2011) 14, 81—86

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RESEARCH

Nurses’ perceptions of their preparation for triage

Kelli Innes, RN, MNa,∗, Virginia Plummer, RN, PhDb,Julie Considine, RN, PhDc

a School of Nursing and Midwifery, Monash University, Wellington Road, Clayton, Victoria 3800, Australiab School of Nursing and Midwifery, Monash University, McMahons Road, Frankston, Victoria 3199, Australiac School of Nursing, Deakin University, 221 Burwood Highway, Burwood, Victoria 3125, Australia

Received 7 January 2011; received in revised form 6 March 2011; accepted 7 March 2011

KEYWORDSTriage;Triage nurse;Emergency nurse;Triage consistency;Triage education

SummaryBackground: Triage is the process of assessment and prioritisation of care for all patients pre-senting to the emergency department (ED). To improve consistency in triage education theTriage Education Resource Book was introduced in 2002, which contained the Australasian Asso-ciation of Emergency Nurses (AAEN) ‘AAEN recommendations for triage education’. The aim ofthe research was to determine if triage education met the standards identified in the ‘AAENrecommendations for triage education’.Method: A retrospective exploratory design was used to examine triage nurses’ perceptions oftheir preparation for triage practice. Participants were divided into two groups based on theircommencement date at triage. Comparisons were made between groups to determine if the‘AAEN recommendations for triage education’ influenced participant triage preparation. Datawas collected by self-report questionnaires. Descriptive statistics, correlations and inferentialstatistics were calculated using SPSS.Results: Triage education provision increased following the introduction of the ‘AAEN recom-mendations for triage education’, however of concern, is the finding that participation in annual

triage auditing has declined since the introduction of the recommendations.Conclusion: The ‘AAEN recommendations for triage education’ have contributed to improve-ments in triage nurse preparation.© 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights

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reserved.

Introduction

Triage is the process of assessment of all patients present-ing to an emergency department (ED) and prioritisation

∗ Corresponding author. Tel.: +61 3 990 53485.E-mail address: Kelli.Innes@monash.edu (K. Innes).

idadtus

1574-6267/$ — see front matter © 2011 College of Emergency Nursing Audoi:10.1016/j.aenj.2011.03.003

f care based on actual or potential severity of illness ornjury.1 An important aspect of triage is consistency in triageecision-making and application of triage categories.2 Therere several factors which contribute to consistency in triage

ecision making. Two important factors are triage educa-ion, which provides nurses’ with specific knowledge tonderpin their decision making,2—5 and a validated triagecale on which to base triage decisions. To this end, the Aus-

stralasia Ltd. Published by Elsevier Ltd. All rights reserved.

82

What is known

• There is little work published on preparation fortriage.

What this paper adds

• This paper adds information about the state ofeducational preparation of triage nurses across 3 Vic-

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ralasian Triage Scale (ATS), was introduced across most EDsn Australia in 2000.6 Given the importance of the triage pro-ess and the impact it may have on quality care and patientutcomes, it is important that triage education be thoroughnd consistent.

To improve national consistency of triage education theriage Education Resource Book (TERB) was introduced in002.6 The TERB contained the Australian Association ofmergency Nurses (AAEN) recommendations for triage edu-ation, the first time such guidelines had been publishedn Australia. The ‘AAEN recommendations for triage educa-ion’ state that triage preparation include (i) a minimumf 8 h theoretical preparation, (ii) 24 h of supervised prac-ice at triage, (iii) access to an experienced triage nurse atll times and (iv) participation in an annual triage audit, asell as recommendations for topics to be addressed in the

heoretical component.d6

im

he aim of this research was to evaluate whether triageducation met the standards identified in the ‘AAEN rec-mmendations for triage education’ and to compare thesendings with triage nurse education prior to 2002 to deter-ine if triage education was influenced by the release of the

AAEN recommendations for triage education’. The researchs important as consistent triage education promotes consis-ent triage practice, and contributes to safe, quality care foratients.

The specific elements of the AAEN recommendations forriage education examined in this study were:

hours of theoretical preparation;hours of supervised practice;access to an experienced triage nurse;participation in triage audits.

ethod

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retrospective exploratory design was used to undertakehe study.

d AAEN was superseded by the College of Emergency Nurses Aus-ralasia (CENA) in 2003. The TERB was replaced with the Emergencyriage Education Kit (ETEK) in 2007.7

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K. Innes et al.

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ata was collected from three (3) metropolitan MelbourneDs between January and April 2006. Monash Medical Centrelayton campus (MMC) and Dandenong Hospital (DH) werewo of the sites and are part of Southern Health which pro-ides health services to a population of over 750,000 peoplen the south-east of Melbourne.8 At the time of the study,MC treated approximately 53,000 ED presentations annu-lly, and DH treated approximately 45,000 ED presentationsnnually. The Northern Hospital (TNH) was the third sitend is the main hospital providing health services to theopulation of Melbourne’s Northern suburbs, and treatedpproximately 63,000 patients annually during the studyeriod.9

articipants

convenience sample of triage nurses was used. The inclu-ion criterion for the sample population was Registeredurses’ who performed, or who were being supported in, theole of triage. Each Registered Nurse at the participating EDsho met this criterion was invited to participate in the study.Clinical Nurse Educator (CNE) from each participating ED

dentified the eligible nurses.

esearch ethics statement

his paper presents the findings of a research study thatdhered to the National Statement on the Conduct of Humanesearch by the Australian National Health and Medicalesearch Council, and has been approved by the Southernealth Human Research Ethics Committee (project number5125C), the Monash University Standing Committee on Ethi-al Research on Humans (2005/840MCC) and Northern Healthuman Research Ethics Committee (19/05). Participation inhe study was voluntary and responses were anonymous.

ata collection tool

espite a comprehensive literature review, no suitable dataollection tool was identified for use in the study. Subse-uently ‘Educational Preparation for the Role of Triage’, waseveloped by the researcher. The questionnaire design com-ined 14 fixed response questions with 15 Likert scale itemsnd five open-ended questions.

There were five stages involved in developing the ques-ionnaire.

The first stage of questionnaire design was to identify thenformation that needed to be obtained in order to answerhe study question. A draft set of questions were developednd evaluated for coherence and clarity by the researchernd research supervisors.10

The second stage of questionnaire development was theeclared testing phase, which aimed to ensure that ques-ions flowed properly and were easily interpreted by eacherson who read them.11 The questionnaire was presented to

n ED Associate Charge Nurse and an ED CNE at Monash Med-cal Centre (Clayton campus). These two senior emergencyurses read through the questionnaire and both stated theuestionnaire was easy to read and understand.

Nurses’ perceptions of their preparation for triage 83

Table 1 Employment characteristics by group.

Experience (months) Group 1 Group 2 U p

Median Range Median Range

Nursing experience 216.00 84—411 76.00 35—444 111.000 <0.001Emergency nursing experience 141.00 48—324 47.00 16—120 52.500 <0.001Emergency nursing experience prior to triage 12.00 1—132 29.00 6—84 379.000 0.004

Number of shifts worked (per fortnight) n % n % �2 p

7 or less 18 54.5 2 5.3 21.200 <0.001*

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The third stage of questionnaire design involved estab-lishing both face and content validity of the questionnaire.Validity of the questionnaire was established by an expertpanel review, composed of two expert triage nurses whohad previously participated in a national triage review anda quantitative research expert. All three experts agreed thatthe questionnaire had face and content validity.

The fourth stage of questionnaire development was toestablish reliability. Reliability was established by unde-clared piloting of the questionnaire on a group of six triagenurses from Southern Health, not involved in the study.

The fifth stage of questionnaire development was a finalrevision of the questionnaire. The order of questions wasrevised, but given the positive feedback in stage four ofquestionnaire development, the content and structure ofeach question remained the same.10

Data collection

Data collection took place from January to April 2006 atthe three sites. Eligible participants received an envelopewhich contained a plain language statement and instruc-tions on how to return the questionnaire. The envelopeswere then placed in the participants’ staff mail. No directcontact was made with the participants. A self-addressedenvelope was attached to the questionnaire allowing partic-ipants to anonymously return their completed questionnairevia post to the researcher. Alternatively, a box was set up inthe staff common area of each site and participants wereable to place their completed questionnaires in the boxanonymously.

Data analysis

Responses were collected, scored and entered into SPSS(Version 14.0). Descriptive statistics was used to describenominal and ordinal data. Data was reported from an aggre-gate of all participants, followed by group comparisons preand post the introduction of ‘AAEN recommendations fortriage education’. Relationships between variables and sig-

nificance were established using Mann—Whitney U (U) test,Pearson Chi-Square (�2) test and Fishers Exact Test (* exact).Content analysis was used to identify themes in qualitativeresponses.

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36 94.7 21.200 <0.001*

esults

n total 71 triage nurses participated in the study (MMC —1, DH — 29 and TNH — 21). Participants were divided intowo groups according to the date of commencement in theriage role. Each group contained approximately the sameumber of participants, with 33 participants in Group 1 (par-icipants who commenced triage prior to the introduction ofhe ‘AAEN recommendations for triage education’ in 2002)nd 38 participants in Group 2 (participants who commencedriage following the introduction of ‘AAEN recommendationsor triage education’ in 2002 or thereafter).

articipant characteristics

articipants reported a median of 119 months (range5—444) general nursing experience and 60 months (range6—324) emergency nursing experience. Participants alsoeported a median of 24 months (range 1—132) emergencyursing experience prior to undertaking the triage role. Theajority of participants (n = 51, 71.8%) worked four shiftser week or more (Table 1).

The collection of demographic data allowed participantso be divided into two groups: participants who commencedriage prior to the introduction of the ‘AAEN recommenda-ions for triage education’ in 2002 (referred to as Group 1)nd participants who commenced triage following the intro-uction of ‘AAEN recommendations for triage education’ in002 or thereafter (referred to as Group 2).

The employment characteristics of Group 1 and Group 2articipants were compared to examine if diversity in spe-ialty educational preparation affected individual responsesbout their preparation for the triage role. Group 1 par-icipants had almost three times more nursing experienceU = 111.000, p = <0.001) and emergency nursing experienceU = 52.500, p = < 0.001) than Group 2 participants. Despiteroup 1 participants having more overall emergency nurs-

ng experience, Group 2 participants had more than twices much emergency nursing experience prior to commencinghe triage role (U = 379.000, p 0.004).

ost graduate educational qualifications

here were no significant differences in the completion ofost graduate studies in emergency nursing between Group

84 K. Innes et al.

Table 2 Methods of educational preparation for the triage role by group.

Group 1 Group 2 �2 p

Median Median

Hours of theoretical preparation 4 8 19.291 0.056Hours of supervised practice 8 24 33.828 <0.001

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Participation in triage audit 11 33.3

and Group 2 participants. Emergency nursing was the mostommonly held post graduate qualification for both groupsith 24 participants (72.2%) in Group 1 and 28 participants

73.3%) in Group 2 holding post graduate emergency nurs-ng qualifications. High rates of post graduate qualificationsn emergency nursing were not unexpected given that allarticipants were currently employed in emergency nurs-ng. Participants’ educational preparation for the triage roleas examined to identify if the ‘AAEN recommendations for

riage education’ had been implemented in the EDs studied.In the following section, results are presented for each

lement of the ‘AAEN recommendations for triage educa-ion’: (i) all emergency nurses complete 8 h of theoreticalreparation prior to commencing the triage role, (ii) allovice triage nurses receive 24 h of supervised practice whenommencing triage, (iii) triage nurses have access to anxperienced triage nurse at all times and (iv) triage nurseshould participate in an annual triage audit.

ours of theoretical preparation

n average the 71 participants in this study received 5 h ofheoretical preparation prior to commencing the triage role,h less than that recommended. Group 2 participants spentore time preparing for the triage role (median 8.0 h, range

—20) than Group 1 (median 4.0 h, range 0—30) (�2 = 19.291,= 0.056) (Table 2).

Participants reported a variety of methods of educationalreparation for the triage role, supervised practice (n = 54,6.1%) was the most common method (Table 3).

ours of supervised practice

f the 71 study participants, 32 participants (45%) reportedeceiving at least 24 h supervised practice. Eleven par-

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Table 3 Methods of educational preparation for the triage role b

Group 1

n %

Supervised practice 22 66.7Learning package 16 48.5University lectures 13 39.4Tutorials 12 36.4In Service 10 30.0Health network based triage workshops 6 18.2

* Exact.

7 18.9 418.000 0.005

icipants in Group 1 (33.3%) reported they received noupervised practice when commencing the triage role.roup 1 participants had a median of 8 h of supervisedractice (range 0—40) (Table 2). By comparison all Groupparticipants reported receiving supervised practice when

ommencing the triage role. Group 2 participants receivedmedian of 24 h of supervised practice (range 8—43,

2 = 33.828, p = 0.001).

ccess to an experienced triage nurserom the 71 participants in the study, only 26 participants36%) reported having access to an experienced triage nurset all times. Less than one-quarter of the Group 1 par-icipants (n = 7, 21.2%) reported access to an experiencedriage nurse at all times and two-thirds of Group 1 par-icipants (n = 23, 67.9%) reported access to an experiencedriage nurse most of the time. Three participants fromroup 1 (9.1%) reported that they did not have access to anxperienced triage nurse. By comparison half of Group 2 par-icipants (n = 19, 50.0%) reported access to an experiencedriage nurse at all times, while the other half of Group 2articipants (n = 19, 50%) reported access to an experiencedriage nurse most of the time. This between-group differ-nce in access to an experienced triage nurse was significantU = 418.000, p = 0.005).

articipation in triage audits

triage audit aims to evaluate triage practice by comparingriage decisions with the ATS guidelines.6 Of the 71 study

articipants, only 18 participants (25%) reported participat-ng in an annual triage audit. In contrast to the other findingsn this study which indicated that Group 1 participants hadess participation in triage education, Group 1 participants

y group.

Group 2 �2 p

n %

38 100 14.989 <0.001*

33 86.8 12.152 <0.00120 52.6 1.244 0.26527 71.1 8.585 0.00313 34.2 0.123 0.72629 76.3 23.881 <0.001*

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Nurses’ perceptions of their preparation for triage

actually had a higher participation rate in annual triageaudits (n = 11, 33.3%) than Group 2 participants. Less thanone-quarter of Group 2 participants (n = 7, 18.9%) indicatedthey had participated in an annual triage audit (U = 418.000,p = 0.005) (Table 2).

Discussion

Key findings

The research found that triage education in the sitesstudied, increased after the introduction of ‘AAEN rec-ommendations for triage education’, and that since theirrelease, triage education has met the recommendations out-lined. The first key finding was that Group 2 participantsreported double the quantity of theoretical preparationcompared with Group 1 participants. Group 2 participantshad a median of 8 h theoretical preparation prior to com-mencing the triage role which is in keeping with the AAENrecommendation that participants receive a minimum of 8 htheoretical preparation.

An unexpected finding from this study was that onequarter of all Group 1 participants (n = 8, 24.2%) reportedreceiving no preparation at all prior to commencing thetriage role. Further, Group 2 participants received anaverage of three times more supervised practice (median24 h) than Group 1 participants (median 8 h). While thereis no direct research to indicate that supervised prac-tice improves consistency in triage decision making, manyauthors advocate the use of supervised practice.12—18 Super-vised practice aims to facilitate the linking of theory topractice14 and is used to develop experience and promotecompetence and confidence. By focusing on decision makingand prioritisation, supervised practice has been reported toimprove patient outcomes by developing the triage decisionmaking process.13,18

The between-group difference in duration of supervisedpractice is perhaps reflective of the introduction of the‘AAEN recommendations for triage education’ which aim toimprove consistency in triage decision-making. The benefitsof supervised practice, combined with the finding that Group2 participants received the recommended 24 h of supervisedpractice, implies that Group 2 participants are well preparedfor the triage role. Future research may determine whether24 h of supervised practice actually improves consistency intriage decision-making but the findings in this study indicatethat extra preparation for the triage role results in increasedconfidence at triage.

The second key finding was that less than one quarterof Group 1 participants and half the participants in Group2 reported they had access to an experienced triage nurseat all times, while they were novice triage nurses’. Experi-enced triage nurse’ are a valuable resource for novice triagenurses and may support the decision making process.19 It isdifficult to know if this finding reflects true lack of provisionof access to an experienced triage nurse or if participantsperceived that access to an experienced triage nurse was

not available.

The geographical isolation of the triage area may con-tribute to the perception that novice triage nurses do nothave access to an experienced triage nurse at all times. How-

Ted

85

ver it could be argued that all triage nurses have phoneccess to an experienced triage nurse in the form of theurse in charge of the ED. Further, triage decisions areommonly monitored by the nurse in charge of each shiftia information management systems and review of patientharts. Such supervision may be considered as access ton experienced nurse without that nurse being physicallyresent at the triage desk. Perhaps orientation of noviceriage nurses should place emphasis on available resourcesor the triage nurse. The ‘AAEN recommendations for triageducation’ did not provide evidence to support the provisionf access to an experienced triage nurse at all times.

The third key finding was that more Group 1 partici-ants (n = 11, 33.3%) participated in an annual triage audithan Group 2 participants (n = 7, 18.9%). The finding thatess Group 2 participants partake in annual triage auditshan Group 1 participants is significant and unexpected, asroup 2 participants have reported a higher level of par-icipation in all other areas of triage education. It is alsourprising that only one-quarter (n = 18, 25.4%) of partici-ants adhered to the AAEN recommendation to participaten an annual triage audit. ‘‘Self audits can be a very effec-ive tool . . . to identify deficiencies and resolve them beforeeal problems occur’’[20], p. 81. The identification of bothorrect and erroneous triage decisions provides both posi-ive reinforcement for the good decisions and an avenue fordjusting practice where poor primary triage decisions aredentified.20,21 Given the benefits of triage auditing, EDs andrganisations need to adjust their practice to allow greaterarticipation in auditing of triage decisions. There is a needor EDs and organisations to encourage auditing by allocatingime for triage nurses or others, such as CNE, to undertakehe auditing process. An important aspect of others, suchs CNE, undertaking the auditing process is the need forppropriate and effective feedback to the triage nurses.

imitations

his study had a number of limitations that should be con-idered when interpreting the results. The first limitationn the study was that data collection relied solely on self-eporting. Reported perceptions of readiness for triage doot necessarily correlate with performance in the triageole. However the study aimed to measure participant per-eptions and the use of a self-reporting questionnaire wasdeal for this.

Finally, the results from this study are specific to thehree sites examined and cannot be generalised across otherDs. Extraneous variables, such as variations in program con-ent or supervised practice provided across sites were notxamined and may have influenced results. To some extenthis is addressed by the reports of similar educational out-omes from similar international studies,22 however furtheresearch on a larger scale would improve the generalisabilityf these findings.

ummary

he research has revealed consistent approaches to triageducation since the introduction of the ‘AAEN recommen-ations for triage education’ in 2002. A major finding of

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he research was that triage education across the threeites studied does meet the majority of recommendationsutlined in the ‘AAEN recommendations for triage edu-ation’. Further, between-group comparisons showed thathere were positive changes to triage education practicesollowing the introduction of the ‘AAEN recommendationsor triage education’.

rovenance and conflicts of interest

ulie Considine is a Deputy Editor with the Australasianmergency Nursing Journal but had no role in the editorialnd peer review or decision-making process. No other con-icts of interest were declared by the remaining authors.his paper was not commissioned.

unding

here was no funding attached to the development of thisrticle.

eferences

1. Considine J, LeVasseur S, Charles A. Consistency of triage inVictoria’s emergency departments: guidelines for triage edu-cation and practice. In: Report to the Victorian Department ofHuman Services. Monash Institute of Health Services Research;2001.

2. Crellin D, Johnston L. Poor agreement in the applicationof the Australasian Triage Scale to paediatric emergencydepartment presentations. Contemporary Nurse 2003;15:48—60.

3. Considine J, Ung L, Thomas S. Clinical decisions using thenational triage scale: how important is postgraduate educa-tion? Accident and Emergency Nursing 2001;9:101—8.

4. Dilley S, Standen P. Victorian nurses demonstrate concordance

in the application of the National Triage Scale. EmergencyMedicine 1998;10:12—8.

5. Kelly AM, Richardson D. Training for the role of triage in Aus-tralasia. Emergency Medicine (Fremantle) 2001;13:230—2.

K. Innes et al.

6. Gerdtz M, Ashby R, Richardson D, Grant F, McCallum-PardyT, O’Brien D. Education resource book. 1st ed. Canberra,Australia: Australian Commonwealth Department of Health andAgeing; 2002.

7. Gerdtz M, Considine J, Sands N, Stewart C, Crellin D, PollockW, et al. In: Ageing DoHa, editor. Emergency triage educationkit. Canberra: Commonwealth of Australia; 2007.

8. Southern Health. Southern Health; about us. SouthernHealth; 2006. Available from: www.southernhealth.org.au/whatis page sh.htm [cited 2006 23rd September].

9. Northern Health. About Northern Health; 2003. Available from:www.nh.org.au [cited 2006 23rd September].

10. Polit D, Beck C. Nursing research: principles and methods.7th ed. Sydney, Australia: Lippincott Williams & Wilkins;2004.

11. De Vaus D. Surveys in social research. 5th ed. St. LeonardsN.S.W.: Allen and Unwin; 2002.

12. Hutchings A, Williamson G, Humphreys A. Supporting learnersin clinical practice: capacity issues. Issues in Clinical Nursing2005;14:945—55.

13. Kilminster S, Jolly B. Effective supervision in clinicalpractice settings: a literature review. Medical Education2000;34:827—40.

14. Lambert V, Glacken M. Clinical support roles: a review of theliterature. Nurse Education in Practice 2004;4:177—83.

15. Lambert V, Glacken M. Clinical education facilitators: a litera-ture review. Issues in Clinical Nursing 2005;14:664—73.

16. Benner P. From novice to expert: excellence and power in clin-ical nursing. USA: Addison-Wesley; 1984.

17. Williamson G, Webb C. Supporting students in practice. Journalof Clinical Nursing 2001;10:284—92.

18. Jones A. The influence of professional roles on clinical support.Nursing Standard 2001;15:42—5.

19. Fry M. Triage. In: Curtis K, Ramsden C, Friendship J, editors.Emergency and trauma nursing. Sydney: Elsevier; 2007. p.84—91.

20. McDaniel J. Auditing OSHA’s proposed self-auditing policy.Occupational Health and Safety 2000;69:80—1.

21. Walker S. Reflective practice in the accident and emer-gency setting. Accident and Emergency Nursing 1996;4:

27—30.

22. Fernandes C, Wuerz R, Clark S, Djurdjev O. How reliable isemergency department triage? Annals of Emergency Medicine1999;34:141—7.