Accident and Emergency Nursing (2005) 13, 214219

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

An educational framework for triage nursing based

on gatekeeping, timekeeping and decision-making
processes
Margaret Fry RN CITN MEd PhD (Emergency Clinical Nurse Consultant)
Colleen Stainton RN BN MN DNS (Professor) b
a
b

a,*

Emergency Department, St. George Hospital Kogarah, Sydney, NSW 2217, Australia
Faculty of Nursing and Midwifery, University of Sydney, Sydney, NSW 2006, Australia

Received 4 June 2005; accepted 24 September 2005

KEYWORDS

Summary Introduction: The role of the triage nurse has emerged in response to
growing community demand for a more accessible and efficient emergency department (ED) service. The focus of triage research has been on measuring outcomes
and improving the delivery of emergency care. This has meant that the context of
care, and triage processes and practices have remained concealed. Thus, little evidence about the role and ways to prepare nurses for this role is available. The aim of
this study was to provide insight and understanding needed to educate and support
the triage nursing role in Australian EDs.
Methods: A 12-month ethnographic study of triage nursing practice was conducted
in Sydney metropolitan EDs. Data were then collected from participant observation
in four EDs and interviews with 10 triage nurses. Analysis used standard content and
thematic analysis techniques.
Findings: Findings reveal that notions of timeliness, efficiency and equity are
embedded in a culture of ED care. This sustains a particular cadence of care to
which triage nurses are culturally oriented. Triage nurses maintain, negotiate and
restore this cadence of emergency care by using gatekeeping, timekeeping and decision-making processes.
Conclusion: The comprehensive study of triage nursing has led to the development
of an educational framework based on the processes of gatekeeping, timekeeping
and decision-making.
c 2005 Elsevier Ltd. All rights reserved.

Gatekeeping;
Timekeeping;
Decision-making;
Emergency processes;
Cultural behaviour

* Corresponding author. Tel.: +61 02 9350 1650.

E-mail address: frym@sesiahs.nsw.gov.au (M. Fry).

0965-2302/$ - see front matter c 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2005.09.004

Educational framework for triage nursing

Introduction
To date, the complexity of triage practice and
challenges experienced by nurses in this role are
not well understood. While there are policies and
guidelines available, they fail to provide an adequate understanding of how triage nurses select urgency codes, investigations and allocate beds and
resources. Further, little is known about the texture, challenges and experiences of daily triage life
as prevailing literature has largely ignored the context in which the nursing role operates, the processes implicit in practice, and how extended
practices influence behaviour (Fry and Burr, 2002;
Gerdtz and Bucknall, 1999).
The inadequate understanding of the context
and processes within which this clinical role is set
significantly limits the educational support that
can be offered to triage nurses. It is clear that
more understanding of the triage nurses experience in routine practice and of the context and
processes embedded and negotiated daily need to
be fully understood. To address this knowledge
gap, an ethnographic study was undertaken to
understand the experience of triage nurses and
how they made sense of reality (Fry, 2004). This
is needed if educators are to adequately prepare
and support nurses for the triage role, now and into
the future.

215
interviews with 10 triage nurses. To preserve privacy and confidentiality, pseudonyms are used for
participating nurses. Analysis used standard content and thematic analysis techniques. Ethical
approval was obtained from the University of
Sydney Human Ethics committee and participating hospitals.

Findings
Triage Nurses need to keep order and control, you
need fairness and equity thats what we have to
do (Peter)
Findings reveal triage nursing is embedded in a
culture of ED care that is based on notions of efficiency, timeliness and equity. These cultural notions give shape to a context of care that bring
meaning and understanding to, and of, embedded
triage processes and practices. Together these notions give rise to a particular cadence of emergency care. Triage nurses, highly motivated to
maintain, negotiate and restore this cadence of
emergency care, use gatekeeping, timekeeping
and decision-making processes to ensure triage
work is achieved, and patient safety and resource
utilisation appropriate.

The process of gatekeeping

Methods
Ethnography provided a theoretical perspective for
identifying and describing the context, practice
and processes of triage nurses. A 12-month time
frame was selected to provide the opportunity to
observe a wide variety of triage events, activities,
and participants in metropolitan EDs (Level 4 and
6). The four EDs were purposely selected as they
had a dedicated triage role, shared the computer
system (EDIS), onsite diagnostics and radiology
services, used the Australasian Triage Code Scale,
and had a similar patient casemix (NSW Health,
2001).
The triage sample group was identified using
the Delphi technique (Fry and Burr, 2001b) and
surveys (Fry and Burr, 2001a). A purposeful sample of 10 triage nurses at Clinical Nurse Specialist1 level participated in the study. Data were
then collected from participant observation and

Clinical Nurse Specialist in the Australian context is an

experienced clinician (>4 years) within a speciality or holds a
postgraduate specialty qualification (NSW Health, 1997).

You have to decide what theyre here for, then

decide what are the best investigations and then
where they should go for treatment (Peter)
Gatekeeping processes generate a pattern of patient movement, a geography of care, which sustain beliefs of efficiency, timeliness and equity.
Triage nurses are able to understand and regulate
a geography of care by distinguishing between
areas nominated as inside and outside. Inside
refers to numerous clinical patient areas, such as
resuscitation, trauma or acute rooms, which are
equipped and designated for particular patient
treatments. Outside refers to the waiting area,
and clerical and triage spaces. The cultural meanings, implicit in each clinical area, reflect varying
levels of timeliness, efficiency and control, and
characterise workspaces into places. Sally explains You work your way through the department, you work your way through consults,
resuscitation and trauma rooms, learning to problem solve, developing your skills first and then
you go to triage.
Through the triage nurses understanding of
place gatekeeping patient movement is made

216
possible. The cultural meanings embedded in
place solidify triage goals values and expectations through which patient movement is ordered
and shaped. This gives structure to gatekeeping
processes, brings coherence to practice and sustains the cadence of emergency care. Gatekeeping
place enables triage nurses to accomplish role
purpose and orientate themselves in various practice situations and interactions. It is within gatekeeping processes, that triage nurses balance
notions of urgent and non-urgent, appropriate
and inappropriate, and right and wrong. Consequently, it is gatekeeping processes that make possible ED patient movement and bed allocation
determining which patients get what, when,
where, why and how quickly. Triage nurse knowledge of clinical areas and learned notions of
place enable workspace boundary alignments
appropriate to patient group and interventional
need to be managed.

The process of timekeeping

Things change all the time at triage. Theres
always possibilities. You know thats what triage
is (about), weighing up where youre going to get
the time (Sally)
The study reveals that time is profoundly important within a culture of ED care. In this context,
time is a cultural touchstone by which triage nursing works, behaviour and talk is measured and evaluated. Different meanings of time punctuate
clinical areas hierarchically ordering practice
and staff activities. For example, triage code
guidelines reflect the fragmentation of urgent
time, whereby specific patient groups, events and
activities give meaning to the rush of time. Temporal reality constitutes a routine cadence pattern
that is understood, shared and recognised by all.
But it is the triage nurse who is the timekeeper,
regulating time through the allocation of an appropriate urgency triage code and/or their ability to
implement fast tracking practices. Achievement
and goal fulfillment is characterised by timeliness
and efficiency and lays the foundation for triage
expectation. An understanding of the patterns of
patient movement and gatekeeping processes is
essential for the triage role of timekeeping.
The value of efficiency and timeliness fuses ED
time with its own cultural rhythm that links triage
nurses to practice and makes them feel accountable for the provision of emergency care. Consequently, incidents such as patient overcrowding
can disrupt the cadence of care whereby the
nurses sense of control, safety and well being in

M. Fry, C. Stainton
the practice of triage nursing is disrupted. However, by allocating a code and fast tracking patient
care triage nurses sustain the normal timing of
care to which they are culturally oriented. Time
represents, defines and compromises the accomplishment of care practices within the triage role
and positions triage nurses as temporal workers,
mediators of cultural timing for patients and staff.

The process of decision-making

If the right informations given, then we can
speed up the process of patients seeing doctors
(Peter)
The study identifies that decision-making processes are central to triage gatekeeping and timekeeping processes the practical accomplishment
of triage. Triage nurses face a reality in which gatekeeping and timekeeping practices involve a range
of decisions about patient movement which frame
a timing of care that generates an overall cadence
of ED work.
Triage decision-making processes intertwine
with cultural knowledge providing nurses with the
ways of doing, understanding of what is known
and what is to be believed particular to patient
groups. Cultural dimensions help make sense of
decision-making and secure, justify and sustain beliefs of efficiency, timeliness and equity. Having
learnt the meanings applied to patient groups,
place and the timing of care, triage nurses are
able to make effective choices and plans about patient urgency, the need for a bed and likely interventions. It is in this way that cultural meanings
powerfully shape and inform understanding of individual decision-making.
To make effective choices, triage nurses use four
key decision-making processes that include: information gathering, pattern recognition, probability
judgements and diagnosing. All triage nurses, in order to reach a decision, gather information. This
composes of patient observation and history, physical assessment and vital signs. Triage nurses do not
routinely collect vital sign information but when
they do, patterns of knowing are triggered and different decisions are made. Triage nurses rely on
pattern recognition to gauge patient urgency, direct
choice, accelerate decision-making and build confidence to act. Probability judgement helps triage
nurses to determine a patients need for a bed and
desirable location for intervention and treatment.
Probability judgement brings a sense of control
and order to the triage role. Pattern recognition
and probability judgement fuse with information
collected into a working diagnosis that enables a

Educational framework for triage nursing

course of events to be predicted and the work of triage accomplished. Sally summed up the sentiments
of others You know to me when Im triaging, Im
always thinking in my mind, Whats their underlying diagnosis? because thats what youre doing,
putting it altogether. Triage nurse skill in determining a patients likely diagnosis enables decisions
about urgency, bed allocation, staff utilisation and
extended activities to be planned.
Triage decision-making processes balance the
cadence of ED work. Harmony is thus achieved
by the triage nurses identification of the right
urgency code, working diagnosis, clinical area
and allocation of resources. In practice, triage
nurses, by having developed these decision-making skills and learnt the meanings applied to clinical areas, patient groups, staff roles and medical
urgency, can and do make complex clinical decisions about patient urgency, bed allocation,
investigations and interventions.

Discussion
The ethnographic study has made explicit three
processes underpinning the practical accomplishment of triage nursing. The processes of gatekeeping, timekeeping and decision-making are central
to the smooth running of emergency departments,
patient safety and resources utilisation. Knowledge
of these processes can form the foundation of a
conceptual framework for triage education. This
framework provides emergency educators with a
different way to understand, teach, define and support triage nursing practice from a theoretical
perspective.

Gatekeeping as an educational framework

Gatekeeping skills and knowledge are essential to
accomplish triage work. Triage nurses require an
understanding of patient movement, conditions
and interventions relevant to place. It is apparent
that preparation for the triage role requires a program that enables emergency nurses to have the
opportunity to become familiar with different ED
workspaces and their associated patient groups,
activities, practice roles and functions. An orientation to each clinical area provides opportunity to
gather information to build patterns of knowing,
cognitive templates of patient urgency, as they relate to clinical groups. Further, it secures their
sense of belonging, develops their understanding
of the cadence of emergency care and builds confidence in their clinical skills and cognitive abilities.

217
The transition to working outside has educational implications for triage nurses. The triage
nurse located outside is away from where the
rest of the nursing team is located. Therefore, triage
nurses need to be prepared for this changing context
of practice if they are to adjust, enjoy and succeed
in the role. However, for some triage nurses, in a
setting that desires teamwork, action and belonging
the repositioning of the nurse outside gives rise to
feelings of vulnerability, conflict and isolation.
While triage nurses would go inside to survey clinical areas, this practice also served to resolve feelings of vulnerability and isolation as contact with
the team sustained a sense of belonging. Within this
framework, triage nurses can be prepared to anticipate this changing context of practice.
In addition, there has been no consideration in
the prevailing literature of developing and preparing nurses to engage and work with clerical staff
outside. The study provides sufficient evidence
for emergency educators to consider, develop and
understand the relationship between triage nurse
and clerical staff. Triage nurses need to understand
clerical staff role and function. This aspect of
working outside needs to be incorporated into triage education programs.
This study has shown that cultural meanings are
deeply internalised in triage gatekeeping practices.
This framework provides scope, for the first time,
to consider and reflect on the impact of cultural
meanings on gatekeeping practices. Emergency
educators, by making explicit the interrelatedness
of belief systems and gatekeeping processes, can
begin to unravel triage expectations and assumptions, and thereby assist triage nurses to better
understand their behaviour, emotions and ways of
thinking. In this way, educators can better ensure
nursing knowledge is bound by consciousness and
embedded meanings within the unconscious are explored and made explicit. Thus, the conceptual
framework promotes and supports the development of patterns of thinking that assist considered,
ethical and well articulated triage responses.

Timekeeping as a conceptual educational

framework
Triage timekeeping practices ensure patient safety
through the recognition of patient urgency and the
intervention of fast tracking practices. Within this
framework, timekeeping practices are best developed by providing emergency nurses with the opportunity to work within all clinical areas whereby
they learn to discriminate between more or less
urgent, anticipate interventions and staff utilisation

218
requirements. To ensure that practice is in keeping
with nursing philosophy timekeeping policies and
guidelines need to be made explicit within triage
education programs.
Triage nurses skillfully work with senior emergency doctors in order to optimise timekeeping
practices and patient safety. Thus, a positive relationship with senior emergency doctors enables triage nurses to accommodate changes in the context
of practice, where patient safety and care may
otherwise have been compromised. Educators can
ensure emergency nurses are allocated sufficient
time to establish trust relationships with emergency medical staff. This will better support nurses
as they undertake the transition to becoming the
triage nurse.
Timekeeping processes are threaded with competing knowledge systems, beliefs and expectations
that engage an array of moral notions making tradeoffs necessary. Triage nurses can be prepared to
anticipate these moments of tension when for example patient timekeeping goals and expectations differ from those of the triage nurse. The collision of
different timekeeping expectations can create
adversarial situations within triage practice. Within
this conceptual framework, educators can create
opportunities to discuss these broader dimensions
when inducting nurses into the triage role. In this
way, triage nurses can be prepared for encountering
role tension, specifically when their actions do not
meet patient or their own care expectations.
The importance allocated to efficiency and timeliness enabled triage nurses to extend the scope of
their practice in ways that were acceptable to medicine. To educate triage nurses to undertake fast
tracking practices such as radiology (Fry, 2001) or
analgesia (Fry et al., 2004) emergency educators
need first to ensure that fast tracking policies are
available, relevant to, and consistent with, innovative practice, thereby cultivating in nurses the desire to adhere to professional boundaries. In this
way, policies will ensure a tighter grip within practice and remain relevant to the changing context of
care. Second, by staggering the introduction of extended activities, triage nurses can develop the
necessary skills and confidence to implement and
safely manage timekeeping practices. As a result
of timekeeping practices, only experienced emergency nurses should be oriented to the triage role.

Decision-making as a conceptual educational

framework
The ability of the triage nurse to make decisions
and allocate clinical areas to patients would be se-

M. Fry, C. Stainton
verely limited without advanced decision-making
skills. This dimension of the educational framework
proposes that educators focus on information gathering, pattern recognition, probability judgement
and diagnostic decision-making skills. This study
also provides evidence that haemodynamic information adds a level of certainty to triage assessment. While triage nurses did not routinely
collect vital sign information, when they did different decisions were made. Therefore, patient haemodynamic information provides a valuable
reference point for triage decision-making processes. Based on this study and others (Cooper
et al., 2002; Gerdtz and Bucknall, 2001) emergency
educators should encourage novice triage nurses to
obtain patient haemodynamic information to build
confidence in triage decision-making.
Triage education programs need to provide
nurses with adequate practical experience in order
to develop advanced decision-making skills. Thus,
triage nurse preparation will ensure that nurses
are alert to subtle patient nuances and conditions
and are able to discriminate between more or less
urgent cases. By using this conceptual framework,
triage nurse decision-making can be developed to
enable a confident diagnosis to be made, and the
prediction of care, and allocation of an urgency
code and clinical area.

Conclusion
Ethnographic data has provided emergency educators with a more sensitive and sophisticated
understanding of triage nursing and of the cultural
context within which it is situated. The study, by
making explicit the processes of gatekeeping,
timekeeping and decision-making, has identified
how nurses manage, experience and accomplish
the challenging role of triage nursing in Australia.
By accommodating these processes within a broad
conceptual educational framework, educators are
able to plan triage programs that lead to more
disciplined practice, responsible decision-making
and more tolerant work practices.

Acknowledgements
This study is part of the completed work for the
Doctor of Philosophy in the Faculty of Nursing and
Midwifery at the University of Sydney. The College
of Nursing Vivian Bullwinkle Scholarship and NSW
Nurses Registration Board Category 5 scholarship
supported this doctoral work.

Educational framework for triage nursing

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