AUTHORS
All the authors are SRN, Adv. Dip. Nursing (Emergency)
The purpose of this study is to identify the difficulties that the triage nurse encounters and the measures that could be adopted to allay the situation. A study of 122 registered nurses from 6 general hospitals in Singapore was conducted. A questionnaire was used to collect data on the personal, communication, orientation and induction program, and psychological aspects of the subjects. Some of the findings were consistent with studies done overseas where casual factors such as language barrier which hampers the efficient communication process, and the scarcity of triage related courses. Nurses have expressed that the availability of triage related courses, a comprehensive orientation-induction program, and language classes could help them perform triage more efficiently.
INTRODUCTION
Accident and Emergency Department (A & E) is a busy facility associated with long queue and waiting time, attending to patients with major or minor illnesses. In the past decade, there has been a significant increase in the number of clients seeking treatment in the A & E, mostly with non-urgent ailments, carrying with them the concept of a 'one stop convenience". In an effort to cope with this increasing demand and ensuring smooth client flow, triage systems and protocols have been utilized.
Managing this increasing volume of patients can be achieved through proper acuity rating according to the severity of their ailments. Nevertheless, these professionals must possess the skill and competency to arrive at an accurate decision on the priority rating of the client. (Yates, 1989; Rock and Pledge, 1991 and Dolan, 1993). In Singapore, triage is done by doctors, triage trained and non trained nurses. The challenging and dynamic elements in triage would facilitate the rendering of emergency care to the patients, and enhance the efficiency of the department. However, the increasing demand of their competency and accountability might impose a feeling of inadequacy among the professionals. Rowe (1992) found that American nurses are generally not comfortable with triaging and as a result are often inconsistent in their triage decision. This is mainly due to their inexperience and inadequate knowledge. The authors believe that nurses in Singapore could have similar experience as their American counterparts, and there is a need to explore the phenomenon in the local context.
This study aims to identify the difficulties experienced by nurses in triaging, and the possible solution to overcome them. It is also the authors' aim that such experience gathered in this descriptive research could be shared to improve the provision of quality emergency care.
LITERATURE REVIEW
The word triage is derived from the French verb "trier", which means "to pick or to sort". Triage dates back to the French military which used the word to designate a "clearing hospital" for the battlefield wounded (Sheehy, 1992). The A&E adopted the triage system in the early 1960's, when the demand for emergency services began to outpace the available emergency resources. In the United States, the number of A&E visits tripled since 1958 (Rund and Rausch, 1981).
Majority of the literature available address the problem of long waiting time. Few have looked into the difficulties encountered by the triage nurses. The authors perceived that local triage nurses are faced with the problems of communication breakdown, lack of training in triage and inadequate orientation and induction programmes. As such they could be psychologically unprepared to adopt the demanding role of triaging.
Communication
The major component in triaging is communication which allows the nurse to obtain specific history to aid the accurate disposition of the client, as supported by Purnell (1991). Kelly (1994) asserts that communication skills is imperative for the triage nurse to convey concern and reassurance. However, communication could also cause the nurses to feel uncomfortable during triaging (Purnell, 1993).
Induction Programme
Dolan (1993) asserts that a comprehensive and adequate induction program is crucial for novice nurses to function efficiently in the triage room. According to Purnell (1993), 31 out of 54 states in America emphasize the importance of induction programmes and conduct such programmes extensively to enable nurses to work effectively in the triage area.. Purnell (1993) suggested that a clinical preceptorship component should be included to guide novice nurses.
Training
Purnell (1991) and Buckles and Carew (1990) both claim that the triaging requires more knowledge than in the general area and should be manned by a competent health care professional. Dolan (1993) highlights that due to a lack of training, emergency nurses are often slow in recognizing important details in the process of assessment. Bailey, Hallam and Hurst (1987) state that a suitably educated first-level nurse is needed to determine the seriousness of patients' problems. This is further advocated by Rowe (1992) who claims that novice triage nurses without appropriate training are unable to concentrate on the relevant aspects of patients' complaints. This would eventually hamper effective triage decision making.
Psycho-social
Rowe (1992) asserts that the lack of clinical experience in the triage area often cause nurses to feel uncomfortable and unable to concentrate during triaging. Rock and Pledge (1991) claims that a registered nurse with at least two years of experience in the clinical area seldom encounter psychological problems during triaging. In agreement, Yates (1987) feels that triage officers should be senior nurses as they are more mentally and psychologically prepared.
METHOD
This research is exploratory and descriptive. The population for this study is registered nurses working in the emergency departments of six general hospitals in Singapore. The tool is a questionnaire designed based on the authors' clinical experience and the literature review. The questions are categorized into 4 sections to collect personal data, and data on the communication, induction programme and psychological aspect.
Permission was sought and granted from the ethical committees of the six hospitals. Participation was voluntary and implied consent was presumed upon the return of the completed questionnaires. All identities of the hospital and nurses were kept strictly anonymous and confidential.
The questionnaires were to disseminate to all registered nurses in the various emergency departments. Boxes were placed in their manager's office for them to submit the completed forms anonymously. The data collection period was 5 days.
RESULTS AND DISCUSSION
The total number of subjects were 122, of which 17 (14%) were incomplete and cannot be used.
Table 1 - Years as Registered Nurse
| DURATION | ( % ) |
| < 1 year | 13 |
| 1 - 5 Years | 25 |
| > 5 Years | 62 |
Table 2 - Years in the A&E
| DURATION | ( % ) |
| < 1 year | 29 |
| 1 - 5 Years | 42 |
| > 5 Years | 28 |
Communication
Of all the subjects, 2% rated themselves poor in communicating with patients while 25.3% rated themselves excellence in this aspect. All had barrier in foreign language barrier such as Bangladesh and Thai. Half of them always faced difficulties getting a foreign interpreter. Most of the nurses suggested a need to learn such languages. With the awareness of the increasing population of foreign workers, it is recommended that the hospitals can make arrangement with the various embassies to provide on-call interpreters or language programmes for nurses.
Induction Program
Only 63.7% of the nurses find their induction program adequately prepared them to work in the triage room. Purnell (1993) advocated that a guided preceptor-ship clinical component should be included depending on the nurse's previous experience and progress. Thus there is a need to re-examine the way preceptorship is conducted locally. Extending its period could also be beneficial to the nurses. The authors recommend the hospitals to use a standard, such as the Emergency Nurses Association. (1991) Standards, as a guide to improve their induction programme.
Training
Table 4 - % of Emergency Nurses who had attended courses
| VARIOUS FIELDS | (%) |
| ACLS | 14.3 |
| BCLS | 79.1 |
| ATLS | 0.05 |
| BTLS | 40.7 |
| TRIAGE | 68.1 |
| ECG | 65.9 |
| RADIOLOGY | 15.4 |
There should be concern with regard to the alarming findings that the 81% of the trained triage nurses feel that they have knowledge deficit. Perhaps reassessing the content of the triage workshop would be beneficial. The authors would recommend the hospitals conduct comprehensive triage workshops incorporating topics such as ECG, Radiology, Stress Management and Communication as deemed useful and necessary by the nurses surveyed. The Department should also train all their staff in ACLS, BCLS and BTLS. Conducting a refresher course for the trained staff could also be helpful.
Another area to look into is conducting regular follow up Triage Case Conference through critical incident and reflection. The conference pinpoints mistakes which have been made, correct patient acuity rating and emphasize proper documentation. These are dynamic learning processes which would increase awareness, prevent similar mistakes and increase the nurses' triaging knowledge through sharing of experience.
Psycho-social
Table 8: Mental readiness to triage
| DURATION | ( % ) |
| < 1 year | 45 |
| 1 - 5 Years | 83 |
| > 5 Years | 72 |
While 74% of nurses untrained to triage were always mentally prepared to do triaging, only 82% of the triage-trained nurses were confident to do so. This could be an indication of the inadequacy in the training programmes for triage nurses. However, it could also be related to the clinical experience of the each individual nurse.
Table 8 related the number of years of experience of a nurse to their mental readiness to work in the triage area. While it is not surprising that less than half of relatively inexperienced A&E nurses are always mentally prepared, it is interesting to see that 72% of the most experienced nurses are comfortable with their triage work, compared to 83% in those who have relatively inexperienced. It could be an indication that nurses who have worked in the A&E for many years do need to go for refresher courses to update themselves.
LIMITATIONS
As there is a limited amount of relevant literature for reference, many assumptions were made when designing the tool. The questions asked were not exploratory in nature. The causative factors that led to the discomfort of nurses triaging were defined in the tool by the researchers instead of obtaining personally from the A&E nurses, and this is perceived to be a bias factor.
The validity and the reliability of the tool could not be established as no pilot study was done due to time constraints. This also did not allow any modification or improvements to be made
CONCLUSION
The triage role is challenging and demanding, and has been described as the essence of emergency nursing. It has been shown that emergency nurses do face problems in communication especially with foreigners. The psychologically readiness of triage nurses is not satisfactory, mainly due to knowledge deficit and inadequate induction programmes. However, the nurses have suggested possible measures such as modification of current triage courses, and additional training programmes to aid them in performing triage efficiently and with greater confidence. Recommendation for future studies include redefining the function of preceptorship, induction programmes, and identifying the specific types of knowledge deficit in the triage-trained nurses. The triage course should be reviewed and improved to allow nurses to cope with the complexity of triaging.
REFERENCES
Bailey, A., Hallam, K., and Hurst, K. (1983). Triage on trial. Nursing Times, 83(44),65 - 66
Buckles, E., and Carew-McColl, M. (1991). Triage by telephone. Nursing Times, 87(6), 26 - 28
Dolan, B. (1993). Seniority doesn't mean better news. Nursing Standard, 7(38),10
Emergency Nurses Association. (1991). Standards of emergency nursing practice St Louis : Mosby Year Book.
Kelly, K.A. (1994). Referring patients from triage out of the emergency department to primary care settings : one successful emergency department experience. Journal Of Emergency Nursing., 20(6), 458 - 463
Purnell, L.D.T. (1991). A survey of emergency department triage in 185 hospitals: Physical facilities, fast track systems, patient classification system, waiting times, and qualification, training, and skills of triage personnel. Journal Of Emergency Nursing, 17(6), 402 - 407
Purnell, L.D.T. (1993). A survey of the qualifications, special training, and levels of personnel working emergency department triage. Journal Of Nursing staff development, 9(5), 223 - 226
Rock, D., and Pledge, M. (1991). Priorities of care for the walking wounded : triage in accident and emergency . Professional nurse, 6 , 463 - 465
Rowe, J.A. (1992). Nurse educator : triage tool Journal Of Emergency Nursing, 18(6), 540 - 544
Rund, D.A., and Rausch, T.S. (1981). Triage. St Louis : C.V. Mosby.
Sheehy, S.B. (1992). Triage. St Louis : Mosby.
Yates, D.W. (1987). Nursing triage in the accident and emergency department. Journal of Royal Society of Health, 4, 153 - 154
The Professional Nurse, July – September 1997, Vol. 24 No. 3 Page 17 – 19 Publisher – Singapore Nurses Association
Copyright - Not to be reproduced without permission from the authors
Global Worldwide - Emergency Nursing