Triage Decision-Making Skills: A Necessity for all Nurses 
Anita Smith PhD, RN 
Kelly J. Cone PhD, RN, CNE 

Journal for Nurses in Staff Development
January/February 2010 
Volume 26 Number 1
Pages E14 - E19

Abstract

Triage decision making is an essential skill for nurses. Through initial assessment, a nurse must be able to prioritize patient care on the basis of appropriate decision making. The purpose of this article is to present pilot study data on the Triage Decision-Making Inventory, which measures the identification of critical thinking, cognitive characteristics, intuition, and experience when making triage decisions. Establishing reliability and validity of the instrument in a sample of nurses with diverse specialties allows staff development experts to use the inventory to tailor training for new graduates and practicing nurses.


Triage decision making is an essential skill for nurses who provide direct patient care or supervise nurses in both acute care and community settings. Anticipating and immediately identifying potential problems are part of the assessment phase of the nursing process. Triage is prioritizing care and making decisions on the next best steps or interventions. The general assumption is that triage occurs in the emergency room setting, but in actuality prioritizing care is performed in all clinical or community care settings.

The purpose of this article is to present pilot study data on the Triage Decision-Making Inventory (TDMI; Cone, 2000). The TDMI is an instrument originally developed to explore how comfortable emergency department (ED) nurses feel about making triage decisions. The TDMI measures the identification of critical thinking, cognitive characteristics, intuition, and experience when making triage decisions. For the pilot study, the inventory was administered to a sample of registered nurses with diverse clinical specialties to evaluate the reliability and validity of the inventory.

TRIAGE DECISION MAKING

The word "triage" relates to a selection process. The concept is central to the efficient allocation of available resources in the healthcare setting (Mezza, 1992). A summary of triage definitions includes the following characteristics: (a) a process of selecting among a group, (b) sorting into categories, (c) the criteria for categories, (d) the levels of importance for categories, and (e) the preservation of functioning and minimization of loss (Mezza, 1992). Historically, the concept has been linked to and defined in civilian medicine, military medicine, disaster management, and traditional healthcare settings. In a triage setting, nurses must make challenging decisions. Besides focusing on who will survive and who will get the resources, the nurse must have astute assessment skills to categorize patients and to prioritize care (Mezza, 1992). Triage decision making is based on critical thinking, cognitive skills, intuition, and experience (Cone, 2000).

A review of the triage decision-making research emphasizes experience level of the nurse, use of intuition, and various cognitive factors that influence decision making in emergency situations. The research reviewed included studies using samples of emergency nurses and critical care nurses from Canada, Sweden, Australia, and Hong Kong (Andersson, Omberg, & Svedlund, 2006; Chung, 2005; Cioffi, 1998, 2001; Gerdtz & Bucknall, 2001; Goransson, Ehnfors, Fonteyn, & Ehrenberg, 2008; Hicks, Merritt, & Elstein, 2003; Patel, Gutnick, Karlin, Pusci, 2008; Tippins, 2005). The findings from these studies reflect the factors/dimensions of experience, cognitive behaviors, critical thinking, and intuition that the TDMI measures.

Several researchers used quantitative methodology to explore triage decision making. Tippins (2005) used an exploratory approach, with questionnaires and interviews, to examine ED nurses' ability to recognize and manage patient deterioration. The key themes related to recognizing critical illness are pattern recognition, physiological signs and symptoms, and use of intuition. Experience, whether it was general, positive, or negative, was also identified as influential to early identification and response to patient deterioration. Hicks et al. (2003) used a correlational design to examine the relationship of education level, years of critical care experience, and critical thinking skills to the consistency of clinical decision making. The sample consisted of 54 critical care nurses. The findings indicated that critical thinking was not linked to education or experience, but having more years of experience increased the decision-making consistency. Interventions selected via intuitive decision-making processes were more consistent across tasks. Recommendations included providing more experience for nurses because various experiences influence decision making rather than skill level. Thus, there is the possibility that nurses with a variety of experiences in different clinical settings could be comfortable with making triage decisions even if nurses never worked in an emergency setting. Another factor to consider is that exposing nurses and new graduates to various experiences will increase triage decision-making skills.

Most researchers explored the concept of triage decision making with qualitative methods. Andersson et al. (2006) conducted a qualitative study using a sample of 16 ED nurses in rural Sweden to describe factors considered when triaging patients and making triage decisions. Data collection was via observations and a short interview in which nurses would elaborate on how they decided to prioritize patient care. Factors that were important in triaging were skills, personal capacity, work environment, and assessment. High workload and practical arrangement made up the work environment factors. Skills included experience level, knowledge, and intuition. Personal capacity included courage, uncertainty, confidence, and rationality. The nurses in the sample were experienced in emergency nursing, but what is not considered is other specialty experiences and how this would influence triage decision making. Consideration of experience and confidence is needed when fostering triage skills. The TDMI measures the identified skills and personal factors of experience and intuition.

Gerdtz and Bucknall (2001) used a naturalistic approach (a) to describe decision making of triage nurses, (b) to describe data collected to prioritize care, (c) to describe the duration of decision making, and (d) to describe the patient and nurse variables on decision making. This observation study was conducted in adult EDs in metropolitan Melbourne, Australia. A finding discovered by the observational data collection techniques was the number of triage decisions made without physiological data. Because of the lack of physiological data, triage decisions were influenced by subjective factors. The authors stressed the need for further investigation into the study of the subjective factors that affect triage decision making. Subjective factors could include intuition, experience level, and cognitive characteristics of the nurse, which are included in the TDMI.

Chung (2005) used unstructured interviews to explore the triage decision making by emergency nurses in Hong Kong. The sample of seven emergency nurses described their triage decision-making experiences. The resulting themes that emerged included (a) experience of triage decision making, (b) use of information in triage decision-making process, and (c) factors that influence triage decision making. The nurses had 5-11 years of emergency nursing experience. Autonomy, satisfaction, feelings of frustration, and feelings of uncertainty were some of the experiences of triage decision making described. Information used in triage decision making included experience, established triage guidelines, and intuition. Factors that influenced triage decision making were interruptions, time constraints, and lack of formal training. Experience- and intuition-influenced triage decision making are components measured by the TDMI.

Cioffi (1998, 2001) explored decision making in triage assessments and past experiences in decision making in emergency situations. The focus of Cioffi's studies was on decision making in uncertainty. In a descriptive approach, the use of heuristics (probability judgments) in triage decision making by nurses with various experience levels was examined in uncertain circumstances (Cioffi, 1998). Nurses used probability judgments more in uncertain situations with the experienced nurse using more probability judgment. Prior clinical experiences influenced decision making; thus, nurses with varied clinical backgrounds and specialties have a "bank" of experiences that influence probability judgments.

Cioffi (2001) further developed the concept of relying on past clinical experience in making decisions in uncertainty through interviews with 32 expert nurses from wards in a teaching hospital in Australia. The purpose of the exploratory descriptive study was to determine if nurses use past experiences to call for the medical emergency team. Sixty-three percent of the nurses voiced that they used past experiences in their decision-making processes. Past experiences influenced assessments that resulted in a judgment. Past experiences influence heuristic strategies and play an important role in decision making. Cioffi recommended exposure to clinical experience for nursing students and clinical exposure to various settings for the new graduate. This is an important concept that needs to be considered by staff development experts and coordinators of new graduate programs especially when fostering the development of triage decision making.

Qualitative methods were used to examine the thinking strategies of the nurse and the process of triage decision making in EDs in Canada and Sweden (Goransson et al., 2008; Patel et al., 2008). Goransson et al. (2008) used "think aloud" methods and content analysis to depict the cognitive processes and thinking strategies of Swedish emergency room nurses with high and low rates of triage accuracy. Various thinking strategies, such as hypothesis generation and information gathering, invoked by the nurses illustrated the complexity of triage decision making with the authors stating the need for further research to identify the essential skills necessary for this type of decision making. Patel et al. (2008) also investigated the process of triage, the guidelines used, and the factors that influence triage decision making. The sample included nurses working in a large pediatric ED in Canada. Through a naturalistic methodology using ethnographic observation and semistructured interviews, the researchers found that triage decisions were based on nonanalytic processes and intuition among experienced nurses. The qualitative findings describing triage decision making highlight the components of cognitive behaviors, experience, and intuition, factors measured by the TDMI.

The themes of experience, intuition, and cognitive skills surfaced in the triage decision-making research. All of the studies reviewed were in hospital settings with nurses who had specific emergency nursing experience. There are no studies examining the triage decision-making abilities of nurses who work outside the ED, in which nursing care is being delivered by nurses who have a variety of clinical specialties and varying years of nursing experience. Testing and evaluating a triage decision inventory in a diverse sample of nurses provide the impetus to use the inventory in other clinical settings, not just in samples of emergency room nurses. A possible use of the inventory could be as a self-report that guides program planning by staff development educators.

TRIAGE DECISION-MAKING INVENTORY

The TDMI consists of 37 Likert-scaled items and four subscales. The instrument was developed to evaluate triage decision-making skills of emergency room nurses and to determine if there are differences in decision making on the basis of experience (Cone, 2000). Ten expert emergency room nurses described the characteristics, insights, and decision making of nurses working in triage (Cone & Murray, 2002). The items developed for the instrument were based on experience, intuition, assessment skills, critical thinking skills, and communication, which were identified as characteristics of experienced triage nurses. Data from interviews were used to generate items for the new instrument, and nine experts reviewed the content of the items. The content validity index for items was .87. Exploratory factor analysis with maximum likelihood extraction and oblimin rotation was used to establish construct validity in a sample of 208 emergency room nurses from 10 different Midwest hospitals. The statistical findings yielded 37 items, which explained 50% of variance and four subscales: (a) cognitive behaviors, (b) experience, (c) intuition, and (d) critical thinking. The Cronbach alpha was .95 for the entire instrument and ranged from .84 to .89 for the subscales. The test-retest result for of entire instrument was .77 (Cone, 2000).

The subscale of cognitive characteristics is made up of seven items that explain 36% of the variance. These items relate to prioritization, organization, judgment, and knowledge. Five percent of the variance was explained by the factor labeled experience. This subscale has 11 items that evaluate the skills necessary to make decisions and the experience that allows the nurse to ask the appropriate questions in a triage setting. The subscale of intuition has seven items and accounted for 6% of variance. These items dealt with "gut" feelings, inner feelings, or sixth sense. Finally, the factor of critical thinking explained 3% of variance and had 12 items. Critical thinking involves assessing the ability to get information needed to make decisions either through evaluation or communication. Table 1 lists the items for each subscale. The Likert scale has six choices ranging from strongly agree to strongly disagree. A summative score can be obtained for the 37 items (222).

Table 1 - Click to enlarge in new window TABLE 1 Factors and Items in the Triage Decision-Making Inventory

Table 1 - Click to enlarge in new window TABLE 1 Continued

A limitation of this instrument is that it has only been tested in samples of experienced emergency room nurses. If the instrument is valid and reliable in a sample of nurses with varied specialties, the summative score provides a measure to evaluate the characteristics of decision making. For example, a maternal child nurse with 15 years of experience can score the same as an ED triage nurse, but different areas may influence decisions. Although experience comes with time, novice or junior nurses may possess other characteristics that will facilitate triage decision-making skills, such as strong critical thinking skills, use of intuition, and cognitive characteristics. The pilot study was conducted to evaluate the reliability and validity of the inventory in a sample of nurses with diverse clinical specialties.

SUMMARY OF PILOT STUDY

The TDMI was administered electronically to registered nurses enrolled in online coursework at a southeastern university after an institutional review board approval. The registered nurses enrolled in baccalaureate coursework, master's coursework, or doctoral coursework received an invitation to participate in the study as an electronic announcement within the online course. The students were able to read the invitation/information/consent information and then answer the demographic questions, complete the TDMI, and click the submit button. If the student did not want to participate, he or she simply closed the announcement. The collected data were anonymous with no identifying information linked to information submitted. The electronic platform used for data collection was the E College Survey software.

Preliminary analysis demonstrates that the TDMI is a reliable and valid instrument with a sample of nurses with diverse clinical experiences. Five hundred eighty-three nurses participated in this pilot study (84% women and 16% men). The years of nursing experience included 0.9% with 0-1 year of experience, 26.3% with 2-5 years of experience, 27.1% with 6-10 years of experience, 20.1% with 11-15 years of experience, and 25.1% with 16 years or more of nursing experience. Because the nurse received an invitation to participate in the study in each course, the researchers were unable to calculate an accurate response rate because one student could have received the initiation from one to four times depending on number of enrolled courses in the semester. The participants were instructed to only complete the inventory once. Table 2 provides information on the educational preparation and clinical specialty of the pilot sample.

Table 2 - Click to enlarge in new window TABLE 2 Education Preparation and Clinical Specialty of Sample (

Principal component factor analysis with Varimax rotation was used to evaluate the construct validity. Exploratory factor analysis allows the anticipated factors to emerge rather than be forced (DeVellis, 1991). Principal component analysis extracts the maximum variance from each component in a data set, whereas Varimax orthogonal rotation minimizes the number of variables with high loadings on a given component that facilitates interpretation (Tabachnick & Fidell, 2001). The following criteria was used to extract the factors and to determine the number of factors to retain: (a) eigenvalues of 1.00 or above because they provide the total variance explained by each factor (Burns & Grove, 2001), (b) examining the cumulative percent of variance (at least 50%; Pett, Lackey, & Sullivan, 2003), (c) salient loadings (>.30), and (d) conceptual consistency and interpretability.

Preliminary analysis using principal component factor analysis with Varimax rotation was conducted using SPSS version 16. The Kaiser-Meyer-Olkin measure of sampling adequacy was .959. There were 563 nurses who participated; thus, the number of responses per item in inventory (36 items) was 16. (Note that there were 36 items in the pilot data because one item was omitted. The item omitted was I can sort out the information that I do not need to make a triage decision.)

Five factors emerged that explained 64.3% of the cumulative variance. The four factors of cognitive characteristics, experience, critical thinking, and intuition were represented, which reflect the findings in the sample of emergency nurses. The fifth factor consisted of two negatively worded items that were representative of the experience factor. All factor loadings for each factor were greater than .30. This was a preliminary review of data, and the decision was to leave all items in the instrument. The alpha coefficients were as follows: .947 for the entire inventory, .915 for Factor 1 (cognitive characteristics), .94 for Factor 2 (experience), .867 for Factor 3 (critical thinking), .87 for Factor 4 (intuition), and .383 for Factor 5 (negatively worded items for experience). These reliabilities for the scale and four factors are acceptable. Table 3 provides a summary of the preliminary factor analysis and reliabilities.

Table 3 - Click to enlarge in new window TABLE 3 Summary of Factor Analysis

IMPLICATIONS FOR STAFF DEVELOPMENT

Fostering triage decision making in all nurses is essential because prioritizing care improves patient outcomes. The TDMI is an instrument that allows nurses to identify if they feel ready to make triage decisions. The focus of the TDMI is on the general characteristics of triage decision making, cognitive behaviors, experience level, intuition use, and critical thinking rather than particular proficiency skills, disease processes, or protocol of allocating resources. Because the TDMI is a self-report that does not focus on the triage categories established for wartime or disaster settings, it can be used in samples of nurses working outside the ED. The findings within the subscales on the TDMI identify areas in which the nurse needs further education and training to improve competency in decision making. The subscale of cognitive characteristics may indicate that the nurse needs additional support regarding particular skills. If the nurse has a lower score in the area of experience and intuition, then the staff development educators may choose to keep a nurse in orientation longer to provide the necessary time in the practice area for the nurse to obtain critical understanding.

The TDMI should be considered a screening tool and not a final evaluation from a staff development perspective. The results from the TDMI assist clinical educators in developing programs for those nurses with similar issues/needs. If the educator can group staff who need similar education, the facility can decrease costs. The education also is specific to the nurse which promotes staff satisfaction.

In conclusion, this research demonstrated the link between decision making, knowledge, and intuition with clinical experiences. Understanding the triage decision-making skills of nurses with diverse experience levels facilitates an understanding of the education and training needs of nursing staff.

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