Accident and Emergency Nursing (2012) 13, 206-213

Accident and
Emergency
Nursing
www.elsevierhealth.com/journals/aaen

An exploration of accident and emergency nurse

experiences of triage decision making in Hong Kong
Josephine Y.M. Chung RN, MN, BSN(Hon)
No. 11, Chuen On Road, Alice Ho Miu Ling Nethersole Hospital, NT, Hong Kong
Received 4 February 2012; received in revised form 1 July 2012; accepted 2 August 2012

KEYWORDS
Triage;
Triage nurse;
Triage decision
making;
Experience

Summary This study used a descriptive qualitative design to explore emergency

nurse experiences of decision making about triage in Hong Kong. Seven experienced
nurses who were working in three different accident and emergency departments
participated in the study. Unstructured interviews were used to provide the nurses
with opportunities to describe their experiences. The findings fall into three main
categories, including the experience of triage decision making, the use of information in the triage decision-making process, and the factors that influence triage
decision making. Although the experience of triage was generally positive, the
nurses felt frustrated and uncertain in some circumstances. In addition, triage decision making was influenced by a series of factors that occur in daily practice. The
findings of this study have implications for the development of formal triage training
and triage decision-making protocols in accident and emergency nursing. They also
provide positive reinforcement and support to triage nurses that will enhance their
ability to make decisions about triage. Avenues for further research in the area are
recommended.
c 2012 Elsevier Ltd. All rights reserved.

Introduction
The purpose of triage is to prioritize patient urgency among those who attend emergency departments (EDs) (Handysides, 1996). Decision making is
an important component of triage practice (Leprohon and Patel, 1995; Cioffi, 1998; Gerdtz and
Bucknall, 1999; Marsden, 1999; Lyneham, 1998).
Decision making in different clinical settings shares
some fundamental aspects. However, unlike other
E-mail address: engex@netvigator.com
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doi:10.1016/j.aaen.2012.08.003

clinical settings, there are some key differences

in triage decision making. Gerdtz and Bucknall
(1999) summarized how the nature of triage requires the nurse to act on decisions as an independent practitioner. Firstly, the triage nurse is
geographically isolated from the rest of the ED
and is required to make decisions without input
from colleagues. Secondly, the triage nurse has
the sole responsibility of providing care for all patients in the waiting area until resources are available within the accident and emergency (A&E)
department. Thirdly, the triage nurse may refer

2012 Elsevier Ltd. All rights reserved.

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong
non-urgent patients to the appropriate health care
providers, and that will expedite the care of semiand non-urgent patients in the waiting area (Emergency Nurse Association, 1992). Finally, the triage
nurse has a unique overview of the workload of
the department, and plays a central role in managing the flow of patients through the department
(Nuttall, 1986; Rice and Abel, 1992). However,
McCaughan (2002) argues that in practice, nurses
usually make decisions collaboratively and rarely
make decisions alone. They seek information in
the form of advice from their colleagues and other
professionals on how to act when faced with an
uncertain situation. The nature of triage decision
making does not always allow this to take place.
When Lipshitz and Strauss (1997) analyzed 102
self-reports of decision making in uncertain situations, they found that the decision makers distinguished three types of uncertainty: inadequate
understanding, incomplete information, and undifferentiated alternatives. The challenge of triage
decision making is that nurses need to make decisions rapidly and with limited patient information.
Due to time constraints or communication difficulties, these nurses may often make decisions with
incomplete information and a limited understanding of the patients problem. Crouch and Dale
(1994) and Geraci and Geraci (1994) found that
interruptions take place during the triage process.
Thus, the influence of incomplete information may
be further compounded by the nature of the triage
process itself.
Triage decisions are often associated with certain levels of risk to the patient, nurse and the
organization, and might lead to legal consequences (Gerdtz and Bucknall, 1999). Jenis and
Mann (1977) identified two types of clinical decisions: hot decisions, which are unusually complex and result in unpleasant emotional arousal,
and cold decisions which are made when the
risks are minimal (p. 45). Hot decisions are
those decisions made by nurses, and may induce
a certain a degree of stress. Cold decisions
are those that are made following rules, algorithms, or protocols (Bucknall and Thomas,
1997). In Hong Kong, triage guidelines provide
only a reference for triage decision making; the
actual triage decisions rely heavily on the nurses
own judgment. Decision making under these circumstances often creates some degree of stress
and personal risk to the triage nurse and the patient. Increased stress and personal risk within
the clinical environment may lead to a decrease
in the result of the efficiency and effectiveness
of the decision-making process. Bucknall and Thomas (1997) also found that perceived personal and

207

professional risks are factors that may influence

decision making by critical care nurses.
Different triage categorization scales were designed in some countries in the 1990s. These included the Australian National Triage Scale (NTS),
the Manchester Triage Guidelines and some modified national triage guidelines such as the Emergency Severity Index that was recently developed
in the US (Gilboy et al., 1999). Triage scales and
guidelines aim to provide a uniform method to enable an informed triage decision to be made in
relation to a patients treatment priority. Hence,
the focus of triage research in the 1990s was to test
the reliability and validity of these triage scales
(Brillman et al., 1996; George et al., 1996; Bond
et al., 1997; Dent et al., 1999). Such studies focused mainly on measuring the predictability and
reliability of triage categorizing, determining such
things as admission, discharge, death rate, and
length of waiting time. They pointed out that inaccurate category allocations can lead to the inadequate utilization of health resources and adverse
patient outcomes (Gerdtz and Bucknall, 1999).
Using this approach as the only way to understand
triage practice will limit the scope of knowledge
of this contemporary role. Moreover, if research
only focuses on the outcome measures, the factors
that influence the process of triage will be made
irrelevant (Fry and Burr, 2002). Although some
researchers have demonstrated a strong reliability
and validity of some triage guidelines and scales
(Beveridge et al., 1999), triage code allocations
are still inconsistent (Considine et al., 2000). Consistency in applying triage scale means that a patient with a specific problem should be allocated to
the same triage category, irrespective of the institution to which they have presented themselves or
the personnel performing the role of triage
(Considine et al., 2000, p. 202). Various studies
have reported inconsistency in triage category allocation by nurses (Wuerz et al., 1998; Fernandes
et al., 1999), experienced accident and emergency
doctors (Goodacre et al., 1999) and between
nurses and doctors (Song-Seng et al., 2002; Bergeron et al., 2002). In practice, triage nurses seldom rely on triage guidelines alone to make
decisions (Fry and Burr, 2001; Gerdtz and Bucknall,
2000). This is particularly true of experienced
nurses, and may contribute to inconsistent application of the guidelines. (Cone and Murray, 2002).
Several studies that have assessed the triage
process have shown that the main concerns are
about the objective data taken by triage nurses,
such as vital signs (including blood pressure,
pulse and temperature) or examinations such as
those for the blood glucose level, urine tests,

208
neurological observations, or rapid electrocardiograms (Standen and Dilley, 1997; Graff et al.,
2000). Studies have reported that physiological
data are considered less by triage nurses when making acuity decisions (Gerdtz and Bucknall, 2001;
Cooper et al., 2002; Lyneham, 1998). Lyneham
(1998) used a modified grounded theory framework
to validate the hypothetico-deductive decisionmaking model among emergency nurses. She found
that nurses utilized verbal, non-verbal, and other
sources of information in clinical inquiry, whereas
objective measurements were used relatively late
in the process. Salk et al. (1998) conducted a
two-phase, prospective, observational study that
employed a randomized, crossover design in an
emergency department in a university teaching hospital. The study compared triage category allocations that were derived from face-to-face and
telephone triage, and systematically examined the
effect of visual cues, vital signs, and complaintbased protocols on the triage process. Knowledge
of vital signs and use of protocols did not improve
the agreement of triage designations between
groups, which suggested that visual cues may play
an important role in the triage assessment process.
The information used for triage decision making not
only depends on objective data, but also depends
on subjective cues that are perceived by nurses.
Handysides (1996) has pointed out that sometimes
patients have atypical symptoms and vague complaints, and the experienced triage nurse often discovers subtle signs of a serious health problem,
even though all objective data is normal. This subjective assessment strategy is described as gut
feeling or intuition in the literature (Offredy,
1998; Marsden, 1999; Grossman, 1999). It is hoped
that an in-depth exploration of nurses triage decision making experiences will provide new insights
into these issues.

Objective
The objectives of this study are to gain an understanding of the triage decision making experiences
of emergency nurses and of the contextual influences on triage decision making in accident and
emergency departments.

Method
A qualitative research method was chosen and a
descriptive design was used in this study. Fry and
Burr (2002) also agree that in-depth interviews

J.Y.M. Chung
can provide a new way of viewing triage nurses
work within a broader context.

Sampling
Purposive sampling, a commonly applied method,
was used in this study. Purposefully sampling dictates that the researcher focuses on the theoretical needs of the study and the informants
knowledge of the research topic to invite the best
suitable people to participant in the study (Morse,
1991). The participants had to be emergency
nurses who were currently involved in the triage
process with at least 1 year of experience in triage.
Morse and Field (1998) suggest that the sample
size is determined when no new information can be
obtained from further interviews. In this study, no
new information emerged after interviewing seven emergency nurses.

Gaining access and procedures

The Survey and Behavioral Research Ethics Committee of the Chinese University of Hong Kong
and the Joint Chinese University-North Territories
East Cluster Clinical Research Ethical Committee
(Joint CUHK-NTEC Cluster CREC) approved the research. Information sheets, including an explanation of the purpose and procedure of the study,
were sent to emergency nurses who met the study
criteria. All participants were interviewed over a 2month period. Interviews were conducted in a
quiet and private room, and each interview was recorded on tape and transcribed for analysis. The
duration of each interview was approximately
40 min.

Instrument and data collection

In qualitative research, the interviewer is the research instrument. Unstructured open interviews
were conducted to collect the data, because little
was known about the experiences of emergency
nurses in triage decision making (Morse and Field,
1998). To help the participants to tell their stories,
they were first asked to describe their experiences
in triage decision making. Participants who were
uncertain about where to begin were encouraged
to start wherever they wished (Morse and Field,
1998) or at a point that impressed them about triage decision making, as suggested by Streubert and
Carpenter (1995). Moreover, participants were advised to describe their experiences rather than
interpret them. When probing was required, it consisted of tell me more about that or what did

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong
that mean to you?. Immediately after each interview field-notes were recorded to ensure that significant observations, experiences, and thoughts
were not missed.

Data analysis
The interviews were conducted in Cantonese and
the recorded interviews were transcribed verbatim
for analysis. Data analysis was based on the coding
system described by Miles and Huberman (1994).
After going through the data analysis steps, all categories and supporting narrative texts were translated into English. The final transcript and
categories were returned to the participants for
comments, feedback and validation (Leininger,
1994). There was no information feedback from
the participants and they all agreed on the themes
that were generated from the transcripts.

Findings
Demographic characteristic of the
participants
The seven participants worked in three different
emergency departments. All of the participates
were female. The average years of experience
in A&E was 9 years, and ranged from 5 to 11
years. Three of the participants had chosen to
work in the A&E department and the remaining
four were assigned to the department by the hospital. The participants had all received some
training in A&E nursing, but none of them had received any formal training on triage decision
making. Six of them had finished a 1-year emergency-nursing course, which covered minimal
training in triage decision making. Six of the participants had Bachelor of Nursing degrees, and
one had a Masters degree in Nursing.

Nurse experiences of triage decision making

Autonomy and satisfaction
All of the participants reported that they held positive attitudes toward the role of triage decision
making. They reported that this role gave them
much autonomy and satisfaction in triage decision
making.
Feelings of frustration
The participants all expressed that they had
encountered challenges in their triage decision
making at different stages. Challenges from col-

209

leagues and medical teams made them feel

frustrated.
When faced with such challenges, one participant lost confidence in her decision-making skills
when she was a junior. The majority of the participants changed their decisions when they were less
experienced. However, being more experienced,
they now felt more confident with their decisions.
Two nurses reflected that they had tried to assert
their decisions with their senior colleagues and
medical staff.
Feeling uncertainty
The participants understood that it was their
responsibility to make an accurate decision when
prioritizing patient urgency. However, they were
sometimes uncertain in triage decision making.
They felt uncertain when a patients condition
changed during a long waiting period. Uncertainties
such as these made them feel that triage decision
making was stressful and risky. Five participants
shared the same feelings when handling patients
who presented with borderline symptoms
(symptoms that were in between two different categories), particularly during long waiting periods.
Three participants said they would upgrade the patients category depending on the waiting time and
conditions so that they could prevent the deterioration of the condition.
As one participant commented:
. . . if the patients waiting time could be long, say
3-4 h, I would upgrade this category 4 case to category 3. Because. . . you dont know what would
happen if you let them wait for 3-4 h. That would
risk the patients health. . . and so I would upgrade
the category and let them to see the doctor earlier. (Nurse 1)
Two participants mentioned that they would reassess borderline cases during peak periods (long
patient waiting time) and would adjust the triage
category accordingly. Some participants reported
that they would upgrade a borderline patients category during peak periods; two participants reported that they were sometimes hesitant about
doing so because they were worried that their decision might be a burden on other colleagues.

The information used in triage decision

making
Use of experience
Previous clinical experience was the main component in the triage decision-making process according to most of the participants.

210
Two participants specifically identified that recent, impressive experiences had made them more
alert during the decision-making process. Moreover, these experiences had assisted them in
revealing patient critical conditions, even if the
patient presented with non-specific symptoms.
Information from pre-hospital personnel and
patients
One participant mentioned that information from
other professionals such as ambulance staff or
police could affect triage decision making. All
of the participants believed that information given by patients was significant to triage decision
making, but four participants reported that some
patients might not give accurate information in
the triage assessment, which in turn would affect
their ability to allocate an appropriate triage
category.
Intuition
Four participants reflected that they would use
subjective data such as intuition in some situations
to reach triage decisions. These approaches were
internalized and used automatically in the decision-making process.
As one participant commented:
I find that the triage decision making sometimes
depends on my sixth senses, . . .ha, ha. . . sometimes
the data does not reflect the problem of a patient.
However, when you feel something wrong about
the patient, you give them a higher priority.
(Nurse 2)
Triage guidelines and pre-established triage
criteria
Although triage guidelines provided assistance in
their decision making, all of the participants reported that the triage guidelines were simply a reference for triage decision making. They followed
the guidelines loosely, as not all of the situations
relating to patient conditions fitted the guideline
categories. Two participants claimed that they
had followed the triage guidelines when they were
less experienced. Three said that they would refer
to the triage guidelines when they found something
ambiguous.
As one participant said:
The guidelines provide limited and fixed information that might not be adapted to the real situation
when you handle the patient. Sometimes, you cannot find a suitable category to match a patients
case according to the guidelines. (Nurse 1)

J.Y.M. Chung
Four participants reported that some pre-established triage criteria should be followed to make
triage decisions even though they felt that the triage category was not always appropriate for the
patient.

Factors that influence the triage decisionmaking process

Interruptions, time constraints and lack of training
were the factors identified by participants as those
influencing the triage decision-making process.
Interruptions
All of the participants reported that interruptions
usually happened when they were making triage
decisions. For example, other patients enquiries, a
sudden case occurring in the waiting hall, or the
arrival of new patients. Four participants said that
interruptions affected their decision-making
process and sometimes this led to them missing
information from patients.
As one participant described:
If many people are asking you questions or other
patients are suddenly getting into worse conditions,
you need to suspend your triage decision-making
process for a while (to manage the problem). . .
when you get back to the case, you might forget
some information that should be asked your
patient. (Nurse 6)
Time constraints
Although there was no definite time limit set to
reach a triage decision, two participants felt that
it was difficult to make an accurate triage decision
in a short period. They said that time constraints
were an influencing factor in their decision-making
process.
Lack of formal training
Even though all of the participants expressed that
training was an essential factor to facilitate the triage decision making, only two participants highlighted the importance of questioning skills to
help them collect more accurate information during the assessment stage of triage. Four participants mentioned that updated medical knowledge
could help them effectively assess the signs and
symptoms of patients.
Three participants mentioned that receiving
some constructive feedback and advice from colleagues had made a strong impression on them
and could help them to effectively handle similar
cases in the future.

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong

Discussion
The emergency nurses had positive attitudes toward the role of triage. However, they reported difficulties in the process of triage decision making.
The triage nurses experienced uncertainty and felt
they were at risk when making decisions about patients with borderline symptoms and when there
were long waiting periods. These issues have not
been reported in previous studies. One possible
explanation may be that most previous studies have
been quantitative and have focused on the accuracy
and consistency of triage practice. In this study,
nurses experienced uncertainty in allocating a category to patients with borderline symptoms which
may have been because they could not obtain more
precise information from patients. In addition, the
nurses perceived that the longer a patient waited
to see the doctor, the higher the risk of deterioration in their condition. The nurses feared that an
incorrect triage category allocation may lead to a
delay in treatment and at worst, the death of a patient, particularly when waiting a long time. Such
outcomes may have legal consequences.
In managing uncertainty, particularly with borderline patients the majority of nurses reported
that they upgraded the triage category during long
waiting periods. They perceived that adopting this
strategy was safe for both patients and nurses. Less
experienced triage nurses are more likely to make
over-triage decisions (Considine et al., 2000).
Interestingly, the decision to over-triage was also
revealed by experienced emergency nurses in this
study. However, some nurses only considered
upgrading the triage category when dealing with
patients with borderline symptoms during long
waiting periods. This decision strategy suggests
that nurses felt uncomfortable and uncertain under
these circumstances. However, over-triage may
not be considered as good practice for the
emergency service and it may not achieve the ultimate goal of triage. In addition, it will invariably
lengthen the waiting time in the same category
group, and the borderline cases may not really warrant the upgrade. The decision to over-triage may
induce inconsistency in triage category allocations,
because the perception of borderline symptoms
may vary among individual nurses. To reduce
uncertainty and the feeling of risk in triage practice, a clear legal liability of the triage role should
be explained to the nurses to make sure that their
performance is not influenced by unnecessary anxiety. Moreover, triage protocols could be used as a
supporting tool for triage decision making in patients with borderline symptoms.

211

Most of the nurses in this study described the

experience of being challenged during triage decision making. Another local study produced similar
findings (Lau, 2001), whereby challenges from coworkers were reported as a factor that influenced
triage decision making. This issue was also reported
by Cone and Murray (2002), who found that triage
nurses thought that their peers did not always respect or support their decisions. A possible reason
is that nurses have no uniform triage education
and different training backgrounds between physicians and nurses may contribute to a lower level
of agreement in triage categorization. Hamers
et al. (1994) point out that judgment will differ
in different domains between nursing and medicine
knowledge. Standen and Dilley (1997) asserted that
uniform triage training can ensure that all triage
nurses work from the same knowledge base and
use the same principles to assess and categorize
patients.
The majority of the nurses admitted that past
experiences played an important factor in their triage decision making, which is also described in previous literature (Cone and Murray, 2002; Cioffi,
1998). The nurses reported that experience of similar cases or recent and impressive cases helped to
make them more alert in the decision-making process. These experiences helped them to reveal
critical conditions. Moreover, most nurses reported
that they used intuition in the triage decision-making process. This subjective decision-making approach is referred to as the representative
heuristic (Cioffi, 1997, p. 189). A number of studies have reported that triage nurses, usually those
who are more experienced, use the representative
heuristic in triage decision making (Lyneham, 1998;
Marsden, 1999; Cioffi, 1998; Gerdtz and Bucknall,
2001). Intuition may be used as a result of individual exposure to information that pertains to particular cases such as nurses past clinical experiences,
and exposure to case reports in professional journals (Schwartz and Griffin, 1986; Benner and Tanner, 1987). Cioffi (1998) argued that the use of
relevant past experiences by nurses in triage decision making could be an advantage in reaching a
decision. However, intuition might bias the real situation in triage decision. Friedlander and Stockman
(1983) point out that people tend to use the closest
information to hand when making decisions, but
the problem with this reasoning approach is that
what is available may not be suitable in each individual case, and can result in variation in decisions
(Thompson and Dowding, 2002). Moreover, if
nurses use this closed-minded assumption (p.
87) they fail to show that their intuitions are sound

212
which can also be a substitute for lack of knowledge (Bandman and Bandman, 1988). Although,
none of the participants expressed that they only
used objective or subjective data to make triage
decisions, it is important that nurses use subjective
information cautiously to avoid bias in the triage
assessment process.
The nurses reported that interruptions were a
frequent problem that influenced triage decision
making. This finding is shared with other studies in
the literature (Crouch and Dale, 1994; Geraci and
Geraci, 1994; Gerdtz and Bucknall, 2001), in which
the results indicated that triage decision making is
likely to be influenced by nursing activities and
environmental factors. Gerdtz and Bucknall (2001)
found that interruptions could significantly increase
the duration of the triage process, which is similar
to the findings of an earlier study (Geraci and
Geraci, 1994) and will further delay emergency
patients from receiving initial triage assessment.
Triangulation of data collection is suggested
when repeating this study (Sandelowski, 1986).
For example, the researcher should collect data
through interviews and on-site observation, so the
data from both sources can be compared to form
a complete picture of the issue.

Conclusion
Triage nurses face diverse patient groups every
day. They should accurately prioritize patients to
receive treatment at the appropriate time. This
study has revealed that triage decision making is
influenced by a series of contextual factors that occur in daily practice. These factors should be taken
into consideration to improve and enhance the
accuracy of triage decision making.

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