Australasian Emergency Nursing Journal (2011) 14, 8186

available at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

RESEARCH

Nurses perceptions of their preparation for triage

Kelli Innes, RN, MN a,, Virginia Plummer, RN, PhD b,
Julie Considine, RN, PhD c
a

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

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

KEYWORDS
Triage;
Triage nurse;
Emergency nurse;
Triage consistency;
Triage education

Summary
Background: Triage is the process of assessment and prioritisation of care for all patients presenting to the emergency department (ED). To improve consistency in triage education the
Triage Education Resource Book was introduced in 2002, which contained the Australasian Association of Emergency Nurses (AAEN) AAEN recommendations for triage education. The aim of
the research was to determine if triage education met the standards identied in the AAEN
recommendations for triage education.
Method: A retrospective exploratory design was used to examine triage nurses perceptions of
their preparation for triage practice. Participants were divided into two groups based on their
commencement date at triage. Comparisons were made between groups to determine if the
AAEN recommendations for triage education inuenced participant triage preparation. Data
was collected by self-report questionnaires. Descriptive statistics, correlations and inferential
statistics were calculated using SPSS.
Results: Triage education provision increased following the introduction of the AAEN recommendations for triage education, however of concern, is the nding that participation in annual
triage auditing has declined since the introduction of the recommendations.
Conclusion: The AAEN recommendations for triage education have contributed to improvements in triage nurse preparation.
2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

Introduction
Triage is the process of assessment of all patients presenting to an emergency department (ED) and prioritisation

Corresponding author. Tel.: +61 3 990 53485.

E-mail address: Kelli.Innes@monash.edu (K. Innes).

of care based on actual or potential severity of illness or

injury.1 An important aspect of triage is consistency in triage
decision-making and application of triage categories.2 There
are several factors which contribute to consistency in triage
decision making. Two important factors are triage education, which provides nurses with specic knowledge to
underpin their decision making,25 and a validated triage
scale on which to base triage decisions. To this end, the Aus-

1574-6267/$ see front matter 2011 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.aenj.2011.03.003

82

K. Innes et al.

What is known
There is little work published on preparation for
triage.

What this paper adds

This paper adds information about the state of
educational preparation of triage nurses across 3 Victorian EDs.

tralasian Triage Scale (ATS), was introduced across most EDs

in Australia in 2000.6 Given the importance of the triage process and the impact it may have on quality care and patient
outcomes, it is important that triage education be thorough
and consistent.
To improve national consistency of triage education the
Triage Education Resource Book (TERB) was introduced in
2002.6 The TERB contained the Australian Association of
Emergency Nurses (AAEN) recommendations for triage education, the rst time such guidelines had been published
in Australia. The AAEN recommendations for triage education state that triage preparation include (i) a minimum
of 8 h theoretical preparation, (ii) 24 h of supervised practice at triage, (iii) access to an experienced triage nurse at
all times and (iv) participation in an annual triage audit, as
well as recommendations for topics to be addressed in the
theoretical component.d6

Aim
The aim of this research was to evaluate whether triage
education met the standards identied in the AAEN recommendations for triage education and to compare these
ndings with triage nurse education prior to 2002 to determine if triage education was inuenced by the release of the
AAEN recommendations for triage education. The research
is important as consistent triage education promotes consistent triage practice, and contributes to safe, quality care for
patients.
The specic elements of the AAEN recommendations for
triage education examined in this study were:

hours of theoretical preparation;

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

Method
Design
A retrospective exploratory design was used to undertake
the study.

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

Setting
Data was collected from three (3) metropolitan Melbourne
EDs between January and April 2006. Monash Medical Centre
Clayton campus (MMC) and Dandenong Hospital (DH) were
two of the sites and are part of Southern Health which provides health services to a population of over 750,000 people
in the south-east of Melbourne.8 At the time of the study,
MMC treated approximately 53,000 ED presentations annually, and DH treated approximately 45,000 ED presentations
annually. The Northern Hospital (TNH) was the third site
and is the main hospital providing health services to the
population of Melbournes Northern suburbs, and treated
approximately 63,000 patients annually during the study
period.9

Participants
A convenience sample of triage nurses was used. The inclusion criterion for the sample population was Registered
Nurses who performed, or who were being supported in, the
role of triage. Each Registered Nurse at the participating EDs
who met this criterion was invited to participate in the study.
A Clinical Nurse Educator (CNE) from each participating ED
identied the eligible nurses.

Research ethics statement

This paper presents the ndings of a research study that
adhered to the National Statement on the Conduct of Human
Research by the Australian National Health and Medical
Research Council, and has been approved by the Southern
Health Human Research Ethics Committee (project number
05125C), the Monash University Standing Committee on Ethical Research on Humans (2005/840MCC) and Northern Health
Human Research Ethics Committee (19/05). Participation in
the study was voluntary and responses were anonymous.

Data collection tool

Despite a comprehensive literature review, no suitable data
collection tool was identied for use in the study. Subsequently Educational Preparation for the Role of Triage, was
developed by the researcher. The questionnaire design combined 14 xed response questions with 15 Likert scale items
and ve open-ended questions.
There were ve stages involved in developing the questionnaire.
The rst stage of questionnaire design was to identify the
information that needed to be obtained in order to answer
the study question. A draft set of questions were developed
and evaluated for coherence and clarity by the researcher
and research supervisors.10
The second stage of questionnaire development was the
declared testing phase, which aimed to ensure that questions owed properly and were easily interpreted by each
person who read them.11 The questionnaire was presented to
an ED Associate Charge Nurse and an ED CNE at Monash Medical Centre (Clayton campus). These two senior emergency
nurses read through the questionnaire and both stated the
questionnaire was easy to read and understand.

Nurses perceptions of their preparation for triage

Table 1

83

Employment characteristics by group.

Experience (months)

Group 1

Nursing experience
Emergency nursing experience
Emergency nursing experience prior to triage

Group 2

Median

Range

Median

Range

216.00
141.00
12.00

84411
48324
1132

76.00
47.00
29.00

35444
16120
684

111.000
52.500
379.000

<0.001
<0.001
0.004

Number of shifts worked (per fortnight)

2

7 or less
8 or more

18
15

54.5
45.5

2
36

5.3
94.7

21.200
21.200

<0.001*
<0.001*

Exact.

The third stage of questionnaire design involved establishing both face and content validity of the questionnaire.
Validity of the questionnaire was established by an expert
panel review, composed of two expert triage nurses who
had previously participated in a national triage review and
a quantitative research expert. All three experts agreed that
the questionnaire had face and content validity.
The fourth stage of questionnaire development was to
establish reliability. Reliability was established by undeclared piloting of the questionnaire on a group of six triage
nurses from Southern Health, not involved in the study.
The fth stage of questionnaire development was a nal
revision of the questionnaire. The order of questions was
revised, but given the positive feedback in stage four of
questionnaire development, the content and structure of
each question remained the same.10

Data collection
Data collection took place from January to April 2006 at
the three sites. Eligible participants received an envelope
which contained a plain language statement and instructions on how to return the questionnaire. The envelopes
were then placed in the participants staff mail. No direct
contact was made with the participants. A self-addressed
envelope was attached to the questionnaire allowing participants to anonymously return their completed questionnaire
via post to the researcher. Alternatively, a box was set up in
the staff common area of each site and participants were
able to place their completed questionnaires in the box
anonymously.

Data analysis
Responses were collected, scored and entered into SPSS
(Version 14.0). Descriptive statistics was used to describe
nominal and ordinal data. Data was reported from an aggregate of all participants, followed by group comparisons pre
and post the introduction of AAEN recommendations for
triage education. Relationships between variables and signicance were established using MannWhitney U (U) test,
Pearson Chi-Square (2 ) test and Fishers Exact Test (* exact).
Content analysis was used to identify themes in qualitative
responses.

Results
In total 71 triage nurses participated in the study (MMC
21, DH 29 and TNH 21). Participants were divided into
two groups according to the date of commencement in the
triage role. Each group contained approximately the same
number of participants, with 33 participants in Group 1 (participants who commenced triage prior to the introduction of
the AAEN recommendations for triage education in 2002)
and 38 participants in Group 2 (participants who commenced
triage following the introduction of AAEN recommendations
for triage education in 2002 or thereafter).

Participant characteristics
Participants reported a median of 119 months (range
35444) general nursing experience and 60 months (range
16324) emergency nursing experience. Participants also
reported a median of 24 months (range 1132) emergency
nursing experience prior to undertaking the triage role. The
majority of participants (n = 51, 71.8%) worked four shifts
per week or more (Table 1).
The collection of demographic data allowed participants
to be divided into two groups: participants who commenced
triage prior to the introduction of the AAEN recommendations for triage education in 2002 (referred to as Group 1)
and participants who commenced triage following the introduction of AAEN recommendations for triage education in
2002 or thereafter (referred to as Group 2).
The employment characteristics of Group 1 and Group 2
participants were compared to examine if diversity in specialty educational preparation affected individual responses
about their preparation for the triage role. Group 1 participants had almost three times more nursing experience
(U = 111.000, p = <0.001) and emergency nursing experience
(U = 52.500, p = < 0.001) than Group 2 participants. Despite
Group 1 participants having more overall emergency nursing experience, Group 2 participants had more than twice
as much emergency nursing experience prior to commencing
the triage role (U = 379.000, p 0.004).

Post graduate educational qualications

There were no signicant differences in the completion of
post graduate studies in emergency nursing between Group

84

K. Innes et al.

Table 2

Methods of educational preparation for the triage role by group.

Hours of theoretical preparation

Hours of supervised practice

Participation in triage audit

Group 1

Group 2

Median

Median

4
8

8
24

0.056
<0.001

11

33.3

18.9

418.000

0.005

ticipants in Group 1 (33.3%) reported they received no

supervised practice when commencing the triage role.
Group 1 participants had a median of 8 h of supervised
practice (range 040) (Table 2). By comparison all Group
2 participants reported receiving supervised practice when
commencing the triage role. Group 2 participants received
a median of 24 h of supervised practice (range 843,
2 = 33.828, p = 0.001).
Access to an experienced triage nurse
From the 71 participants in the study, only 26 participants
(36%) reported having access to an experienced triage nurse
at all times. Less than one-quarter of the Group 1 participants (n = 7, 21.2%) reported access to an experienced
triage nurse at all times and two-thirds of Group 1 participants (n = 23, 67.9%) reported access to an experienced
triage nurse most of the time. Three participants from
Group 1 (9.1%) reported that they did not have access to an
experienced triage nurse. By comparison half of Group 2 participants (n = 19, 50.0%) reported access to an experienced
triage nurse at all times, while the other half of Group 2
participants (n = 19, 50%) reported access to an experienced
triage nurse most of the time. This between-group difference in access to an experienced triage nurse was signicant
(U = 418.000, p = 0.005).

On average the 71 participants in this study received 5 h of

theoretical preparation prior to commencing the triage role,
3 h less than that recommended. Group 2 participants spent
more time preparing for the triage role (median 8.0 h, range
020) than Group 1 (median 4.0 h, range 030) (2 = 19.291,
p = 0.056) (Table 2).
Participants reported a variety of methods of educational
preparation for the triage role, supervised practice (n = 54,
76.1%) was the most common method (Table 3).

Participation in triage audits

A triage audit aims to evaluate triage practice by comparing
triage decisions with the ATS guidelines.6 Of the 71 study
participants, only 18 participants (25%) reported participating in an annual triage audit. In contrast to the other ndings
in this study which indicated that Group 1 participants had
less participation in triage education, Group 1 participants

Hours of supervised practice

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

Methods of educational preparation for the triage role by group.

Group 1

Supervised practice
Learning package
University lectures
Tutorials
In Service
Health network based triage workshops
Exact.

19.291
33.828

Hours of theoretical preparation

1 and Group 2 participants. Emergency nursing was the most

commonly held post graduate qualication for both groups
with 24 participants (72.2%) in Group 1 and 28 participants
(73.3%) in Group 2 holding post graduate emergency nursing qualications. High rates of post graduate qualications
in emergency nursing were not unexpected given that all
participants were currently employed in emergency nursing. Participants educational preparation for the triage role
was examined to identify if the AAEN recommendations for
triage education had been implemented in the EDs studied.
In the following section, results are presented for each
element of the AAEN recommendations for triage education: (i) all emergency nurses complete 8 h of theoretical
preparation prior to commencing the triage role, (ii) all
novice triage nurses receive 24 h of supervised practice when
commencing triage, (iii) triage nurses have access to an
experienced triage nurse at all times and (iv) triage nurses
should participate in an annual triage audit.

Table 3

2

Group 2

22
16
13
12
10
6

66.7
48.5
39.4
36.4
30.0
18.2

38
33
20
27
13
29

100
86.8
52.6
71.1
34.2
76.3

2

14.989
12.152
1.244
8.585
0.123
23.881

<0.001*
<0.001
0.265
0.003
0.726
<0.001*

Nurses perceptions of their preparation for triage

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

Discussion
Key ndings
The research found that triage education in the sites
studied, increased after the introduction of AAEN recommendations for triage education, and that since their
release, triage education has met the recommendations outlined. The rst key nding was that Group 2 participants
reported double the quantity of theoretical preparation
compared with Group 1 participants. Group 2 participants
had a median of 8 h theoretical preparation prior to commencing the triage role which is in keeping with the AAEN
recommendation that participants receive a minimum of 8 h
theoretical preparation.
An unexpected nding from this study was that one
quarter of all Group 1 participants (n = 8, 24.2%) reported
receiving no preparation at all prior to commencing the
triage role. Further, Group 2 participants received an
average of three times more supervised practice (median
24 h) than Group 1 participants (median 8 h). While there
is no direct research to indicate that supervised practice improves consistency in triage decision making, many
authors advocate the use of supervised practice.1218 Supervised practice aims to facilitate the linking of theory to
practice14 and is used to develop experience and promote
competence and condence. By focusing on decision making
and prioritisation, supervised practice has been reported to
improve patient outcomes by developing the triage decision
making process.13,18
The between-group difference in duration of supervised
practice is perhaps reective of the introduction of the
AAEN recommendations for triage education which aim to
improve consistency in triage decision-making. The benets
of supervised practice, combined with the nding that Group
2 participants received the recommended 24 h of supervised
practice, implies that Group 2 participants are well prepared
for the triage role. Future research may determine whether
24 h of supervised practice actually improves consistency in
triage decision-making but the ndings in this study indicate
that extra preparation for the triage role results in increased
condence at triage.
The second key nding was that less than one quarter
of Group 1 participants and half the participants in Group
2 reported they had access to an experienced triage nurse
at all times, while they were novice triage nurses. Experienced triage nurse are a valuable resource for novice triage
nurses and may support the decision making process.19 It is
difcult to know if this nding reects true lack of provision
of access to an experienced triage nurse or if participants
perceived that access to an experienced triage nurse was
not available.
The geographical isolation of the triage area may contribute to the perception that novice triage nurses do not
have access to an experienced triage nurse at all times. How-

85
ever it could be argued that all triage nurses have phone
access to an experienced triage nurse in the form of the
nurse in charge of the ED. Further, triage decisions are
commonly monitored by the nurse in charge of each shift
via information management systems and review of patient
charts. Such supervision may be considered as access to
an experienced nurse without that nurse being physically
present at the triage desk. Perhaps orientation of novice
triage nurses should place emphasis on available resources
for the triage nurse. The AAEN recommendations for triage
education did not provide evidence to support the provision
of access to an experienced triage nurse at all times.
The third key nding was that more Group 1 participants (n = 11, 33.3%) participated in an annual triage audit
than Group 2 participants (n = 7, 18.9%). The nding that
less Group 2 participants partake in annual triage audits
than Group 1 participants is signicant and unexpected, as
Group 2 participants have reported a higher level of participation in all other areas of triage education. It is also
surprising that only one-quarter (n = 18, 25.4%) of participants adhered to the AAEN recommendation to participate
in an annual triage audit. Self audits can be a very effective tool . . . to identify deciencies and resolve them before
real problems occur[20], p. 81. The identication of both
correct and erroneous triage decisions provides both positive reinforcement for the good decisions and an avenue for
adjusting practice where poor primary triage decisions are
identied.20,21 Given the benets of triage auditing, EDs and
organisations need to adjust their practice to allow greater
participation in auditing of triage decisions. There is a need
for EDs and organisations to encourage auditing by allocating
time for triage nurses or others, such as CNE, to undertake
the auditing process. An important aspect of others, such
as CNE, undertaking the auditing process is the need for
appropriate and effective feedback to the triage nurses.

Limitations
This study had a number of limitations that should be considered when interpreting the results. The rst limitation
in the study was that data collection relied solely on selfreporting. Reported perceptions of readiness for triage do
not necessarily correlate with performance in the triage
role. However the study aimed to measure participant perceptions and the use of a self-reporting questionnaire was
ideal for this.
Finally, the results from this study are specic to the
three sites examined and cannot be generalised across other
EDs. Extraneous variables, such as variations in program content or supervised practice provided across sites were not
examined and may have inuenced results. To some extent
this is addressed by the reports of similar educational outcomes from similar international studies,22 however further
research on a larger scale would improve the generalisability
of these ndings.

Summary
The research has revealed consistent approaches to triage
education since the introduction of the AAEN recommendations for triage education in 2002. A major nding of

86
the research was that triage education across the three
sites studied does meet the majority of recommendations
outlined in the AAEN recommendations for triage education. Further, between-group comparisons showed that
there were positive changes to triage education practices
following the introduction of the AAEN recommendations
for triage education.

Provenance and conicts of interest

Julie Considine is a Deputy Editor with the Australasian
Emergency Nursing Journal but had no role in the editorial
and peer review or decision-making process. No other conicts of interest were declared by the remaining authors.
This paper was not commissioned.

Funding
There was no funding attached to the development of this
article.

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