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 Summary This study used a descriptive qualitative design to explore emergency
Triage; nurse experiences of decision making about triage in Hong Kong. Seven experienced
Triage nurse; nurses who were working in three different accident and emergency departments
Triage decision participated in the study. Unstructured interviews were used to provide the nurses
making; with opportunities to describe their experiences. The findings fall into three main
Experience categories, including the experience of triage decision making, the use of informa-
tion 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 deci-
sion 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 clinical settings, there are some key differences

in triage decision making. Gerdtz and Bucknall
The purpose of triage is to prioritize patient ur- (1999) summarized how the nature of triage re-
gency among those who attend emergency depart- quires the nurse to act on decisions as an indepen-
ments (EDs) (Handysides, 1996). Decision making is dent practitioner. Firstly, the triage nurse is
an important component of triage practice (Lepro- geographically isolated from the rest of the ED
hon and Patel, 1995; Cioffi, 1998; Gerdtz and and is required to make decisions without input
Bucknall, 1999; Marsden, 1999; Lyneham, 1998). from colleagues. Secondly, the triage nurse has
Decision making in different clinical settings shares the sole responsibility of providing care for all pa-
some fundamental aspects. However, unlike other tients in the waiting area until resources are avail-
able within the accident and emergency (A&E)
E-mail address: engex@netvigator.com department. Thirdly, the triage nurse may refer

0965-2302/$ - see front matter c 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2012.08.003
Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 207

non-urgent patients to the appropriate health care professional risks are factors that may influence
providers, and that will expedite the care of semi- decision making by critical care nurses.
and non-urgent patients in the waiting area (Emer- Different triage categorization scales were de-
gency Nurse Association, 1992). Finally, the triage signed in some countries in the 1990s. These in-
nurse has a unique overview of the workload of cluded the Australian National Triage Scale (NTS),
the department, and plays a central role in manag- the Manchester Triage Guidelines and some modi-
ing the flow of patients through the department fied national triage guidelines such as the Emer-
(Nuttall, 1986; Rice and Abel, 1992). However, gency Severity Index that was recently developed
McCaughan (2002) argues that in practice, nurses in the US (Gilboy et al., 1999). Triage scales and
usually make decisions collaboratively and rarely guidelines aim to provide a uniform method to en-
make decisions alone. They seek information in able an informed triage decision to be made in
the form of advice from their colleagues and other relation to a patients treatment priority. Hence,
professionals on how to act when faced with an the focus of triage research in the 1990s was to test
uncertain situation. The nature of triage decision the reliability and validity of these triage scales
making does not always allow this to take place. (Brillman et al., 1996; George et al., 1996; Bond
When Lipshitz and Strauss (1997) analyzed 102 et al., 1997; Dent et al., 1999). Such studies fo-
self-reports of decision making in uncertain situa- cused mainly on measuring the predictability and
tions, they found that the decision makers distin- reliability of triage categorizing, determining such
guished three types of uncertainty: inadequate things as admission, discharge, death rate, and
understanding, incomplete information, and undif- length of waiting time. They pointed out that inac-
ferentiated alternatives. The challenge of triage curate category allocations can lead to the inade-
decision making is that nurses need to make deci- quate utilization of health resources and adverse
sions rapidly and with limited patient information. patient outcomes (Gerdtz and Bucknall, 1999).
Due to time constraints or communication difficul- Using this approach as the only way to understand
ties, these nurses may often make decisions with triage practice will limit the scope of knowledge
incomplete information and a limited understand- of this contemporary role. Moreover, if research
ing of the patients problem. Crouch and Dale only focuses on the outcome measures, the factors
(1994) and Geraci and Geraci (1994) found that that influence the process of triage will be made
interruptions take place during the triage process. irrelevant (Fry and Burr, 2002). Although some
Thus, the influence of incomplete information may researchers have demonstrated a strong reliability
be further compounded by the nature of the triage and validity of some triage guidelines and scales
process itself. (Beveridge et al., 1999), triage code allocations
Triage decisions are often associated with cer- are still inconsistent (Considine et al., 2000). Con-
tain levels of risk to the patient, nurse and the sistency in applying triage scale means that a pa-
organization, and might lead to legal conse- tient with a specific problem should be allocated to
quences (Gerdtz and Bucknall, 1999). Jenis and the same triage category, irrespective of the insti-
Mann (1977) identified two types of clinical deci- tution to which they have presented themselves or
sions: hot decisions, which are unusually com- the personnel performing the role of triage
plex and result in unpleasant emotional arousal, (Considine et al., 2000, p. 202). Various studies
and cold decisions which are made when the have reported inconsistency in triage category allo-
risks are minimal (p. 45). Hot decisions are cation by nurses (Wuerz et al., 1998; Fernandes
those decisions made by nurses, and may induce et al., 1999), experienced accident and emergency
a certain a degree of stress. Cold decisions doctors (Goodacre et al., 1999) and between
are those that are made following rules, algo- nurses and doctors (Song-Seng et al., 2002; Ber-
rithms, or protocols (Bucknall and Thomas, geron et al., 2002). In practice, triage nurses sel-
1997). In Hong Kong, triage guidelines provide dom rely on triage guidelines alone to make
only a reference for triage decision making; the decisions (Fry and Burr, 2001; Gerdtz and Bucknall,
actual triage decisions rely heavily on the nurses 2000). This is particularly true of experienced
own judgment. Decision making under these cir- nurses, and may contribute to inconsistent applica-
cumstances often creates some degree of stress tion of the guidelines. (Cone and Murray, 2002).
and personal risk to the triage nurse and the pa- Several studies that have assessed the triage
tient. Increased stress and personal risk within process have shown that the main concerns are
the clinical environment may lead to a decrease about the objective data taken by triage nurses,
in the result of the efficiency and effectiveness such as vital signs (including blood pressure,
of the decision-making process. Bucknall and Tho- pulse and temperature) or examinations such as
mas (1997) also found that perceived personal and those for the blood glucose level, urine tests,
208 J.Y.M. Chung

neurological observations, or rapid electrocardio- can provide a new way of viewing triage nurses
grams (Standen and Dilley, 1997; Graff et al., work within a broader context.
2000). Studies have reported that physiological
data are considered less by triage nurses when mak- Sampling
ing acuity decisions (Gerdtz and Bucknall, 2001;
Cooper et al., 2002; Lyneham, 1998). Lyneham Purposive sampling, a commonly applied method,
(1998) used a modified grounded theory framework was used in this study. Purposefully sampling dic-
to validate the hypothetico-deductive decision- tates that the researcher focuses on the theoreti-
making model among emergency nurses. She found cal needs of the study and the informants
that nurses utilized verbal, non-verbal, and other knowledge of the research topic to invite the best
sources of information in clinical inquiry, whereas suitable people to participant in the study (Morse,
objective measurements were used relatively late 1991). The participants had to be emergency
in the process. Salk et al. (1998) conducted a nurses who were currently involved in the triage
two-phase, prospective, observational study that process with at least 1 year of experience in triage.
employed a randomized, crossover design in an Morse and Field (1998) suggest that the sample
emergency department in a university teaching hos- size is determined when no new information can
pital. The study compared triage category alloca- be obtained from further interviews. In this study,
tions that were derived from face-to-face and no new information emerged after interviewing se-
telephone triage, and systematically examined the ven emergency nurses.
effect of visual cues, vital signs, and complaint-
based protocols on the triage process. Knowledge
of vital signs and use of protocols did not improve
Gaining access and procedures
the agreement of triage designations between
The Survey and Behavioral Research Ethics Com-
groups, which suggested that visual cues may play
mittee of the Chinese University of Hong Kong
an important role in the triage assessment process.
and the Joint Chinese University-North Territories
The information used for triage decision making not
East Cluster Clinical Research Ethical Committee
only depends on objective data, but also depends
(Joint CUHK-NTEC Cluster CREC) approved the re-
on subjective cues that are perceived by nurses.
search. Information sheets, including an explana-
Handysides (1996) has pointed out that sometimes
tion of the purpose and procedure of the study,
patients have atypical symptoms and vague com-
were sent to emergency nurses who met the study
plaints, and the experienced triage nurse often dis-
criteria. All participants were interviewed over a 2-
covers subtle signs of a serious health problem,
month period. Interviews were conducted in a
even though all objective data is normal. This sub-
quiet and private room, and each interview was re-
jective assessment strategy is described as gut
corded on tape and transcribed for analysis. The
feeling or intuition in the literature (Offredy,
duration of each interview was approximately
1998; Marsden, 1999; Grossman, 1999). It is hoped
40 min.
that an in-depth exploration of nurses triage deci-
sion making experiences will provide new insights
into these issues. Instrument and data collection

In qualitative research, the interviewer is the re-

Objective search instrument. Unstructured open interviews
were conducted to collect the data, because little
The objectives of this study are to gain an under- was known about the experiences of emergency
standing of the triage decision making experiences nurses in triage decision making (Morse and Field,
of emergency nurses and of the contextual influ- 1998). To help the participants to tell their stories,
ences on triage decision making in accident and they were first asked to describe their experiences
emergency departments. 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 tri-
Method age decision making, as suggested by Streubert and
Carpenter (1995). Moreover, participants were ad-
A qualitative research method was chosen and a vised to describe their experiences rather than
descriptive design was used in this study. Fry and interpret them. When probing was required, it con-
Burr (2002) also agree that in-depth interviews sisted of tell me more about that or what did
Exploration of accident and emergency nurse experiences of triage d ecision making in Hong Kong 209

that mean to you?. Immediately after each inter- leagues and medical teams made them feel
view field-notes were recorded to ensure that sig- frustrated.
nificant observations, experiences, and thoughts When faced with such challenges, one partici-
were not missed. pant lost confidence in her decision-making skills
when she was a junior. The majority of the partici-
Data analysis pants changed their decisions when they were less
experienced. However, being more experienced,
The interviews were conducted in Cantonese and they now felt more confident with their decisions.
the recorded interviews were transcribed verbatim Two nurses reflected that they had tried to assert
for analysis. Data analysis was based on the coding their decisions with their senior colleagues and
system described by Miles and Huberman (1994). medical staff.
After going through the data analysis steps, all cat-
egories and supporting narrative texts were trans- Feeling uncertainty
lated into English. The final transcript and The participants understood that it was their
categories were returned to the participants for responsibility to make an accurate decision when
comments, feedback and validation (Leininger, prioritizing patient urgency. However, they were
1994). There was no information feedback from sometimes uncertain in triage decision making.
the participants and they all agreed on the themes They felt uncertain when a patients condition
that were generated from the transcripts. changed during a long waiting period. Uncertainties
such as these made them feel that triage decision
making was stressful and risky. Five participants
Findings shared the same feelings when handling patients
who presented with borderline symptoms
Demographic characteristic of the (symptoms that were in between two different cat-
participants egories), particularly during long waiting periods.
Three participants said they would upgrade the pa-
The seven participants worked in three different tients category depending on the waiting time and
emergency departments. All of the participates conditions so that they could prevent the deterio-
were female. The average years of experience ration of the condition.
in A&E was 9 years, and ranged from 5 to 11 As one participant commented:
years. Three of the participants had chosen to . . . if the patients waiting time could be long, say
work in the A&E department and the remaining 3-4 h, I would upgrade this category 4 case to cat-
four were assigned to the department by the hos- egory 3. Because. . . you dont know what would
pital. The participants had all received some happen if you let them wait for 3-4 h. That would
training in A&E nursing, but none of them had re- risk the patients health. . . and so I would upgrade
ceived any formal training on triage decision the category and let them to see the doctor ear-
making. Six of them had finished a 1-year emer- lier. (Nurse 1)
gency-nursing course, which covered minimal
training in triage decision making. Six of the par- Two participants mentioned that they would re-
ticipants had Bachelor of Nursing degrees, and assess borderline cases during peak periods (long
one had a Masters degree in Nursing. patient waiting time) and would adjust the triage
category accordingly. Some participants reported
that they would upgrade a borderline patients cat-
Nurse experiences of triage decision making
egory during peak periods; two participants re-
ported that they were sometimes hesitant about
Autonomy and satisfaction
doing so because they were worried that their deci-
All of the participants reported that they held posi-
sion might be a burden on other colleagues.
tive attitudes toward the role of triage decision
making. They reported that this role gave them
much autonomy and satisfaction in triage decision The information used in triage decision
making. making

Feelings of frustration Use of experience

The participants all expressed that they had Previous clinical experience was the main compo-
encountered challenges in their triage decision nent in the triage decision-making process accord-
making at different stages. Challenges from col- ing to most of the participants.
210 J.Y.M. Chung

Two participants specifically identified that re- Four participants reported that some pre-estab-
cent, impressive experiences had made them more lished triage criteria should be followed to make
alert during the decision-making process. More- triage decisions even though they felt that the tri-
over, these experiences had assisted them in age category was not always appropriate for the
revealing patient critical conditions, even if the patient.
patient presented with non-specific symptoms.
Factors that influence the triage decision-
Information from pre-hospital personnel and making process
patients
One participant mentioned that information from Interruptions, time constraints and lack of training
other professionals such as ambulance staff or were the factors identified by participants as those
police could affect triage decision making. All influencing the triage decision-making process.
of the participants believed that information gi-
ven by patients was significant to triage decision Interruptions
making, but four participants reported that some All of the participants reported that interruptions
patients might not give accurate information in usually happened when they were making triage
the triage assessment, which in turn would affect decisions. For example, other patients enquiries,
their ability to allocate an appropriate triage a sudden case occurring in the waiting hall, or
category. the arrival of new patients. Four participants said
that interruptions affected their decision-making
process and sometimes this led to them missing
Intuition
information from patients.
Four participants reflected that they would use
As one participant described:
subjective data such as intuition in some situations
to reach triage decisions. These approaches were If many people are asking you questions or other
internalized and used automatically in the deci- patients are suddenly getting into worse conditions,
sion-making process. you need to suspend your triage decision-making
As one participant commented: process for a while (to manage the problem). . .
when you get back to the case, you might forget
I find that the triage decision making sometimes
some information that should be asked your
depends on my sixth senses, . . .ha, ha. . . sometimes
patient. (Nurse 6)
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. Time constraints
(Nurse 2) 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
Triage guidelines and pre-established triage
in a short period. They said that time constraints
criteria
were an influencing factor in their decision-making
Although triage guidelines provided assistance in
process.
their decision making, all of the participants re-
ported that the triage guidelines were simply a ref-
Lack of formal training
erence for triage decision making. They followed
Even though all of the participants expressed that
the guidelines loosely, as not all of the situations
training was an essential factor to facilitate the tri-
relating to patient conditions fitted the guideline
age decision making, only two participants high-
categories. Two participants claimed that they
lighted the importance of questioning skills to
had followed the triage guidelines when they were
help them collect more accurate information dur-
less experienced. Three said that they would refer
ing the assessment stage of triage. Four partici-
to the triage guidelines when they found something
pants mentioned that updated medical knowledge
ambiguous.
could help them effectively assess the signs and
As one participant said:
symptoms of patients.
The guidelines provide limited and fixed informa- Three participants mentioned that receiving
tion that might not be adapted to the real situation some constructive feedback and advice from col-
when you handle the patient. Sometimes, you can- leagues had made a strong impression on them
not find a suitable category to match a patients and could help them to effectively handle similar
case according to the guidelines. (Nurse 1) cases in the future.
Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 211

Discussion Most of the nurses in this study described the

experience of being challenged during triage deci-
The emergency nurses had positive attitudes to- sion making. Another local study produced similar
ward the role of triage. However, they reported dif- findings (Lau, 2001), whereby challenges from co-
ficulties in the process of triage decision making. workers were reported as a factor that influenced
The triage nurses experienced uncertainty and felt triage decision making. This issue was also reported
they were at risk when making decisions about pa- by Cone and Murray (2002), who found that triage
tients with borderline symptoms and when there nurses thought that their peers did not always re-
were long waiting periods. These issues have not spect or support their decisions. A possible reason
been reported in previous studies. One possible is that nurses have no uniform triage education
explanation may be that most previous studies have and different training backgrounds between physi-
been quantitative and have focused on the accuracy cians and nurses may contribute to a lower level
and consistency of triage practice. In this study, of agreement in triage categorization. Hamers
nurses experienced uncertainty in allocating a cat- et al. (1994) point out that judgment will differ
egory to patients with borderline symptoms which in different domains between nursing and medicine
may have been because they could not obtain more knowledge. Standen and Dilley (1997) asserted that
precise information from patients. In addition, the uniform triage training can ensure that all triage
nurses perceived that the longer a patient waited nurses work from the same knowledge base and
to see the doctor, the higher the risk of deteriora- use the same principles to assess and categorize
tion in their condition. The nurses feared that an patients.
incorrect triage category allocation may lead to a The majority of the nurses admitted that past
delay in treatment and at worst, the death of a pa- experiences played an important factor in their tri-
tient, particularly when waiting a long time. Such age decision making, which is also described in pre-
outcomes may have legal consequences. vious literature (Cone and Murray, 2002; Cioffi,
In managing uncertainty, particularly with bor- 1998). The nurses reported that experience of sim-
derline patients the majority of nurses reported ilar cases or recent and impressive cases helped to
that they upgraded the triage category during long make them more alert in the decision-making pro-
waiting periods. They perceived that adopting this cess. These experiences helped them to reveal
strategy was safe for both patients and nurses. Less critical conditions. Moreover, most nurses reported
experienced triage nurses are more likely to make that they used intuition in the triage decision-mak-
over-triage decisions (Considine et al., 2000). ing process. This subjective decision-making ap-
Interestingly, the decision to over-triage was also proach is referred to as the representative
revealed by experienced emergency nurses in this heuristic (Cioffi, 1997, p. 189). A number of stud-
study. However, some nurses only considered ies have reported that triage nurses, usually those
upgrading the triage category when dealing with who are more experienced, use the representative
patients with borderline symptoms during long heuristic in triage decision making (Lyneham, 1998;
waiting periods. This decision strategy suggests Marsden, 1999; Cioffi, 1998; Gerdtz and Bucknall,
that nurses felt uncomfortable and uncertain under 2001). Intuition may be used as a result of individ-
these circumstances. However, over-triage may ual exposure to information that pertains to partic-
not be considered as good practice for the ular cases such as nurses past clinical experiences,
emergency service and it may not achieve the ulti- and exposure to case reports in professional jour-
mate goal of triage. In addition, it will invariably nals (Schwartz and Griffin, 1986; Benner and Tan-
lengthen the waiting time in the same category ner, 1987). Cioffi (1998) argued that the use of
group, and the borderline cases may not really war- relevant past experiences by nurses in triage deci-
rant the upgrade. The decision to over-triage may sion making could be an advantage in reaching a
induce inconsistency in triage category allocations, decision. However, intuition might bias the real sit-
because the perception of borderline symptoms uation in triage decision. Friedlander and Stockman
may vary among individual nurses. To reduce (1983) point out that people tend to use the closest
uncertainty and the feeling of risk in triage prac- information to hand when making decisions, but
tice, a clear legal liability of the triage role should the problem with this reasoning approach is that
be explained to the nurses to make sure that their what is available may not be suitable in each indi-
performance is not influenced by unnecessary anx- vidual case, and can result in variation in decisions
iety. Moreover, triage protocols could be used as a (Thompson and Dowding, 2002). Moreover, if
supporting tool for triage decision making in pa- nurses use this closed-minded assumption (p.
tients with borderline symptoms. 87) they fail to show that their intuitions are sound
212 J.Y.M. Chung

which can also be a substitute for lack of knowl- Brillman, J.C., Dozema, D., Tandberg, D., Skalar, D.P., Davis,
edge (Bandman and Bandman, 1988). Although, K.D., Simma, S., 1996. Triage: limitations in predicting the
none of the participants expressed that they only need for emergency care and hospital admission. Annals of
Emergency Medicine 27 (4), 493-500.
used objective or subjective data to make triage Bucknall, T., Thomas, S., 1997. Nurses reflections on problems
decisions, it is important that nurses use subjective associated with decision-making in critical care setting.
information cautiously to avoid bias in the triage Journal of Advanced Nursing 25 (2), 229-237.
assessment process. Cioffi, J., 1997. Heuristics: servants to intuition in clinical
The nurses reported that interruptions were a decision making. Journal of Advanced Nursing 26 (1), 203-
208.
frequent problem that influenced triage decision Cioffi, J., 1998. Decision making by emergency nurses in triage
making. This finding is shared with other studies in assessment. Accident and Emergency Nursing 6 (4), 184-191.
the literature (Crouch and Dale, 1994; Geraci and Cone, K.J., Murray, R., 2002. Characteristics, insights, decision-
Geraci, 1994; Gerdtz and Bucknall, 2001), in which making, and preparation of ED triage nurses. Journal of
the results indicated that triage decision making is Emergency Nursing 28 (5), 401-406.
Considine, J., Ung, L., Thomas, S., 2000. Triage nurses decision
likely to be influenced by nursing activities and using the national triage scale for Australian emergency
environmental factors. Gerdtz and Bucknall (2001) departments. Accident and Emergency Nursing 8 (4), 201-
found that interruptions could significantly increase 209.
the duration of the triage process, which is similar Cooper, R.J., Schriger, D.L., Flaherty, H.L., Lin, E.J., Hubbell,
to the findings of an earlier study (Geraci and K.A., 2002. Effect of vital signs on triage decisions. Annals of
Emergency Medicine 39 (3), 223-232.
Geraci, 1994) and will further delay emergency Crouch, R., Dale, J., 1994. Identifying feelings engendered
patients from receiving initial triage assessment. during triage assessment in the accident and emergency
Triangulation of data collection is suggested department: the use of visual analogue scales. Journal of
when repeating this study (Sandelowski, 1986). Clinical Nursing 3 (5), 289-297.
For example, the researcher should collect data Dent, A., Rofe, G., Sansom, G., 1999. Which triage category
patients die in hospital after being admitted through emer-
through interviews and on-site observation, so the gency departments. A study in one teaching hospital.
data from both sources can be compared to form Emergency Medicine 11 (2), 68-71.
a complete picture of the issue. Emergency Nurse Association, 1992. Triage Meeting the Chal-
lenge. Emergency Nurse Association USA Publication, Park
Ridge.
Fernandes, C., Wuerz, R., Clark, S., Djurdjev, O., 1999. How
Conclusion reliable is emergency department triage? Annals of Emer-
gency Medicine 34 (2), 141-147.
Triage nurses face diverse patient groups every Friedlander, M., Stockman, S., 1983. Anchoring and publicity
day. They should accurately prioritize patients to effects in clinical judgement. Journal of Clinical Psychology
receive treatment at the appropriate time. This 39 (4), 637-643.
study has revealed that triage decision making is Fry, M., Burr, G., 2001. Current triage practice and influences
affecting clinical decision making in emergency departments
influenced by a series of contextual factors that oc- in NSW, Australia. Accident and Emergency Nursing 9 (4),
cur in daily practice. These factors should be taken 227-234.
into consideration to improve and enhance the Fry, M., Burr, G., 2002. Review of the triage literature: past,
accuracy of triage decision making. present, future? Australian Emergency Nursing Journal 5 (2),
33-38.
George, J.E., Quattrone, M.S., Goldstone, M., 1996. Law and the
emergency nurse. Triage protocols. Journal of Emergency
References Nursing 21 (1), 65-66.
Geraci, E.B., Geraci, T.A., 1994. An observational study of the
Bandman, E.L., Bandman, B., 1988. Critical Thinking in Nursing. emergency triage nursing role in a managed care facility.
Appleton & Lange, London. Journal of Emergency Nursing 20 (3), 189-194.
Benner, P., Tanner, C., 1987. Clinical judgement: how expert Gerdtz, M.F., Bucknall, T.K., 1999. Why we do the things we do:
nurses use intuition? American Journal of Nursing 87 (1) 23- applying clinical decision-making framework to triage prac-
31. tice. Accident and Emergency Nursing 7 (1), 50-57.
Bergeron, S., Gouin, S., Bailey, B., Patel, H., 2002. Comparison Gerdtz, M.F., Bucknall, T.K., 2000. Australian triage nurses
of triage assessments among pediatric registered nurses and decision-making and scope of practice. Australian Journal of
pediatric emergency physicians. Academic Emergency Med- Advanced Nursing 18 (1), 24-33.
icine 9 (12), 1397-1401. Gerdtz, M.F., Bucknall, T.K., 2001. Triage nurses clinical
Beveridge, R., Ducharme, J., Janes, L., Beaulieu, S., Walter, S., decision making. An observational study of urgency assess-
1999. Reliability of the Canadian emergency department ment. Journal of Advanced Nursing 35 (4), 550-561.
triage and acuity scale: interrater agreement. Annual of Gilboy, N., Travers, D., Wuerz, R., 1999. Re-evaluating triage in
Emergency Medicine 34 (2), 155-159. the new millennium: a comprehensive look at the need for
Bond, R.J., Kortbeek, J.B., Preshaw, R.M., 1997. Field trauma standardization and quality. Journal of Emergency Nursing 25
triage: combining mechanism of injury with the pre-hospital (6), 468-473.
index for an improved trauma triage tool. Journal of Trauma: Goodacre, S.W., Gillett, M., Harris, R.D., Houlihan, K.P.G.,
Injury, Infection and Critical Care 43 (2), 283-287. 1999. Consistency of retrospective triage decisions as a
Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 213

standardized instrument for audit. Journal of Accident and Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis,
Emergency Medicine 16 (5), 322-324. second ed. Sage, Thousand Oaks.
Graff, L., Palmer, A.C., LaMonica, P., Wolf, S., 2000. Triage of Morse, J.M., 1991. Strategies for sampling. In: Morse, J.M. (Ed.),
patient for a rapid (5-minute) electrocardiogram: a rule Qualitative Nursing Research: A Contemporary Dialogue.
based on presenting chief complaints. Annals of Emergency Stage, Newbury Park, pp. 127-145.
Medicine 36 (6), 554-560. Morse, J.M., Field, P.A., 1998. Nursing Research: The Applica-
Grossman, V.G.A., 1999. Quick Reference to Triage. Lippincott, tion of Qualitative Approaches, second ed. Stanley Thornes,
Philadelphia. Cheltenham.
Hamers, J.P.H., Huijer Abu Saad, H., Halfens, R.J.G., 1994. Nuttall, M., 1986. The chaos controller emergency department
Diagnostic process and decision making in nursing: a litera- triage. Nursing Times 82 (20), 14-20.
ture review. Journal of Professional Nursing 10 (3), 154-163. Offredy, M., 1998. The application of decision making concepts
Handysides, G., 1996. Triage in Emergency Practice. Mosby, St. by nurse practitioners in general practice. Journal of
Louis. Advanced Nursing 28 (5), 988-1000.
Jenis, I., Mann, I., 1977. Decision Making: A Psychological Rice, M., Abel, C., 1992. Triage. In: Budassi-Sheehy, S. (Ed.),
Analysis of Conflict, Choice and Commitment. Free Press, Emergency Nursing Principles and Practice, third ed. Mosby,
New York. St. Louis.
Lau, P.F., 2001. Decision making of triage nurses in determina- Salk, E., Schriger, D.L., Hubbell, K.A., Schwartz, B.L., 1998.
tion of patients level of urgency in accident and emergency Effect of visual cues, vital signs, and protocols on triage: a
department. Unpublished Masters Thesis, The Hong Kong prospective randomized crossover trial. Annals of Emergency
Polytechnic University. Medicine 32 (6), 655-664.
Leininger, M., 1994. Evaluation criteria and critique of qualita- Sandelowski, M., 1986. The problem of rigor in qualitative
tive research studies. In: Morse, J.M. (Ed.), Critical Issue in research. Advances in Nursing Science 8 (3), 27-37.
Qualitative Research Method. Sage, Thousand Oaks, pp. 95- Schwartz, S., Griffin, Y., 1986. Medical Thinking: The Psychology
115. of Medicial Judgement and Decision Making. Springer, New
Leprohon, J., Patel, V.L., 1995. Decision-making strategies for York.
telephone triage in emergency medical service. Medical Song-Seng, L., Shiumn-Jen, L., Lee, K.T., Tiing-soon, L., Wong-
Decision Making 15 (3), 240-253. Tsai, C., 2002. Evaluation of nurse-physician inter-observer
Lipshitz, R., Strauss, O., 1997. Coping with uncertainty: a agreement on triage categorization in the emergency
naturalistic decision-making analysis. Organizational Behav- department of a Taiwan medical center. Chang Gung Med-
iour and Human Decision Processes 69 (2), 149-163. icine Journal 25 (7), 446-451.
Lyneham, J., 1998. The process of decision-making by emer- Standen, P., Dilley, S.J., 1997. A review of triage nursing
gency nurses. Australian Journal of Advanced Nursing 16 (2), practice and experience in Victorian public hospitals. Emer-
7-14. gency Medicine 9 (4), 301-305.
Marsden, J., 1999. Expert nurse decision-making: telephone Streubert, H.J., Carpenter, D.R., 1995. Qualitative Research in
triage in an ophthalmic accident and emergency department. Nursing. Lippincott, Philadelphia.
NTResearch 4 (1), 44-52. Thompson, C., Dowding, D., 2002. Clinical Decision Making and
McCaughan, D., 2002. What decisions do nurses make? In: Judgement in Nursing. Churchill Livingstone, London.
Thompson, C., Dowding, D. (Eds.), Clinical Decision Making Wuerz, R., Fernandes, C., Alarco, J., 1998. Inconsistency of
and Judgement in Nursing. Churchill Livingstone, London, pp. emergency department triage. Annals of Emergency Medi-
96-108. cine 32 (4), 431-443.