International Emergency Nursing 35 (2017) 25–29

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International Emergency Nursing

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Emergency nurses’ knowledge and experience with the triage process in

Hunan Province, China
Karen Hammad a, Lingli Peng b,⇑, Olga Anikeeva a, Paul Arbon a, Huiyun Du a, Yinglan Li b
a
School of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia
b
Xiangya Hospital, Central South University, Changsha, Hunan Province, China

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Triage is implemented to facilitate timely and appropriate treatment of patients, and is typ-
Received 19 December 2016 ically conducted by senior nurses. Triage accuracy and consistency across emergency departments
Received in revised form 26 May 2017 remain a problem in mainland China. This study aimed to investigate the current status of triage practice
Accepted 31 May 2017
and knowledge among emergency nurses in Changsha, Hunan Province, China.
Method: A sample of 300 emergency nurses was selected from 13 tertiary hospitals in Changsha and a
total of 193 completed surveys were returned (response rate = 64.3%). Surveys were circulated to head
Keywords:
nurses, who then distributed them to nurses who met the selection criteria. Nurses were asked to com-
China
Emergency department
plete the surveys and return them via dedicated survey return boxes that were placed in discreet loca-
Emergency nursing tions to ensure anonymity.
Triage Results: Just over half (50.8%) of participants reported receiving dedicated triage training, which was pro-
Nursing education research vided by their employer (38.6%), an education organisation (30.7%) or at a conference (26.1%).
Hospitals Approximately half (53.2%) reported using formal triage scales, which were predominantly 4-tier (43%)
or 5-tier (34%).
Conclusions: The findings highlight variability in triage practices and training of emergency nurses in
Changsha. This has implications for the comparability of triage data and transferability of triage skills
across hospitals.
Ó 2017 Elsevier Ltd. All rights reserved.

1. Introduction the aim of being reliable and reproducible, and independent of

To facilitate timely treatment of patients that present to hospi-
tal Emergency Departments (EDs) a triage process is often imple-
mented [1]. Triage is usually conducted by a senior nurse in the
ED to ensure that patients are seen and treated in order of their
clinical urgency [2]. Triage also seeks to minimise morbidity, dis-
figurement, pain, emotional distress and patient dissatisfaction
with their care experience [3]. As the number of patients present-
ing to EDs continues to increase worldwide [4], triage enables ED
staff to prioritise patient care so that patients requiring more
immediate care are seen first.
A number of triage scales have been developed, which provide a
verified, professionally accepted and validated decision-making
structure, reducing the degree of subjectivity in the triage
decision-making process [2,4]. Triage scales are developed with
⇑ Corresponding author at: Orthopedics Department, Xiangya Hospital, Central
South University, Changsha 410008, Hunan Province, China.
E-mail address: pll98124@126.com (L. Peng).
the nurse performing triage [3,5]. Other advantages of using formal
triage scales include the generation of comparable and comprehen-
sive information on patient attendance and acuity, which may be
used for resource allocation, measuring system performance, plan-
ning and research purposes [2]. Triage data can also inform and
influence ED workload decisions, human resource requirements
and funding [4].
The most widely used and recognised triage scales are the
Manchester Triage Scale, the Canadian Triage Acuity Scale and
the Australasian Triage Scale [1–4,6]. The Manchester Triage Scale
is predominantly used throughout the UK. It is a 5-point scale that
focuses on key signs or symptoms rather than a tentative medical
diagnosis and is less focused on patients’ ability to provide a
detailed medical history [3]. Separate flowcharts exist for 52 differ-
ent symptoms, allowing nurses to triage patients based on the
severity of their main presenting complaint [2]. The Canadian
Triage and Acuity Scale is another 5-point scale and has been
widely accepted and used in Canada [1,2]. It has good interrater
reliability, and has been demonstrated to be valid, and relatively

http://dx.doi.org/10.1016/j.ienj.2017.05.007
1755-599X/Ó 2017 Elsevier Ltd. All rights reserved.
26 K. Hammad et al. / International Emergency Nursing 35 (2017) 25–29
easy to use and apply in various health care settings [4]. The scale
is based on a presumptive disease diagnosis made from a detailed
history or description of the patient’s presenting problem [3].
While this scale is primarily focused on the provision of timely care
to those who most urgently require it, it also takes into account the
concept of customer service. Therefore, the scale also prioritises
providing care to patients with less urgent problems within a rea-
sonable time frame that would meet patients’ expectations [4]. The
Australasian Triage Scale was first developed and implemented in
Australia in 1993 and was substantially revised in 2000. It is also a
5-point triage scale, with patients allocated to different categories
based on their need for time-critical intervention, the potential
threat to their life from their presenting problem and the need to
relieve suffering [2,3,6].
In mainland China, most EDs do not have a dedicated emer-
gency triage system in place and there is a shortage of appropri-
ately trained triage nurses [1]; however, large urban hospitals are
increasingly adopting triage scales [7]. It has been noted that triage
accuracy is an ongoing problem in China, yet unsolved by any one
‘‘gold standard” triage method [8,9]. A review of the literature
examining the current state of ED triage in mainland China showed
wide variation across the country in terms of how patients are
triaged [10]. The review also noted limitations in triage training
for nurses and confusion regarding the minimum experiential
and knowledge requirements for those undertaking triage as part
of their role [10].
In 2012 a national guideline for triage practice was released by
the central Chinese government, which refers to the design of nor-
mative flow in the emergency department [11]. This document
provides guidance on patient treatment options, the arrangements
for ED patients and the management of the quality of medical care
in the ED. The guideline specifies that nurses should undertake the
role of triage and that triage needs to be provided on a 24 h per day
basis. Furthermore, nurses assigned to triage duty should have at
least five years of nursing experience. The guideline instructs
nurses to record patient demographic details, presenting problem,
any treatment provided at triage, and the disposition of the patient,
along with an assigned triage category in the patient record. The
guideline promotes a 4-tier scale whereby Tier A includes life-
threatening cases, requiring immediate and aggressive interven-
tions, Tier B includes serious cases with a potential threat to life,
limb or function requiring rapid intervention, Tier C includes
urgent, acute symptoms without a potential threat to life, limb or
function, and Tier D includes patients with mild or non-urgent con-
ditions without evidence of deterioration [11].
The aim of this study was to explore the experience and roles of
emergency nurses in Changsha, Hunan Province, China.
2. Method
The study explored the roles and experience of emergency
nurses in Hunan Province, China, who are engaged in the role of
ED triage.
2.1. Setting
The setting was 13 tertiary hospitals located in Changsha,
Hunan Province, China. These hospitals varied in size and patient
throughput. The smallest of the 13 hospitals has a total of 1200
inpatient beds, 20 beds for observation in the ED and 10 beds in
the resuscitation room, and averages 150 patients per day. The lar-
gest hospital has 3500 inpatient beds, 45 beds for observation in
the ED and 15 beds in the resuscitation room, and averages 300
patients per day.
2.2. Participants
Participants included registered nurses with experience in ED
triage who were aged 18 years and over. Participants’ roles
included Junior Nurses (with Diploma or Masters Degree and less
than five years of nursing experience), Senior Nurses (Diploma
holders with over five years of nursing experience or Masters
Degree holders with over one year of nursing experience), Nurses
in Charge (experienced nurses responsible for managing nurses
in their department), Associate Professors (Associate Chiefs of
Nursing with extensive knowledge and experience, similar to a
Nurse Practitioner) and Professors (senior professionals with
extensive knowledge and experience in the field).
Surveys were circulated to head nurses of the ED from each par-
ticipating hospital who then distributed them to nurses who met
the selection criteria. The inclusion criterion was a nurse currently
working as a triage nurse within the ED, while the exclusion crite-
rion was a nurse who had previously worked as a triage nurse
within the ED, but currently holds a different position in the
department.
2.3. Data collection
The researchers used a survey they had adapted from Gorans-
son [12]. Nurses were asked to complete the surveys and return
them via a dedicated survey return box located in each of the par-
ticipating hospitals. The boxes were placed in discreet locations
away from foot traffic to ensure that completed surveys could be
returned anonymously. The completion of a survey was taken to
indicate voluntary participation and informed consent to be
involved in the research project. The surveys were in Chinese
(Mandarin) and took approximately 20 min to complete. Com-
pleted surveys were collected over a period of 1 month from 12
March 2015 to 12 April 2015.
2.4. Data analysis
The translation of the surveys into English was undertaken by
members of the research team fluent in Chinese and English. From
a sample of 300 participants, a total of 193 completed surveys were
returned at the conclusion of the study (response rate = 64.3%).
Quantitative survey data were analysed using SPSS software ver-
sion 22, while text responses were thematically analysed without
the use of specialised software due to the limited range and length
of responses.
2.5. Ethics approval
The study was approved by the Ethics Committee of Xiangya
Hospital, Changsha and the Hunan Emergency Nursing Association,
as well as the Flinders University Social and Behavioural Research
Ethics Committee (Project Number 6566). Participants gave
informed consent by completing the questionnaire, and their pri-
vacy, confidentiality and right to withdraw from the study were
upheld at all times.
3. Results
The majority of participants in this study were female (97.4%)
and aged between 25 and 34 years (65.8%). The majority of partic-
ipants (80.8%) had completed a Bachelor Degree in Nursing. Just
under half of all participants were employed as a senior nurse
(47.2%), with 24.9% and 25.4% employed as a junior nurse and
nurse in charge, respectively. Most participants had between one
and nine years of both nursing and emergency nursing experience
 K. Hammad et al. / International Emergency Nursing 35 (2017) 25–29 27

prior to commencing their triage role, and approximately half of Table 2

the participants had between one and four years of experience in Hospital characteristics and triage arrangements.

a triage role. Table 1 presents the demographic characteristics of Hospital beds n %

the study participants. 500–1000 39 20.2
With regards to the study setting, the majority of study partic- >1000 154 79.8
ipants (79.8%) were employed in large hospitals that have over a Type of emergency department
1000 bed capacity. The majority of participants worked in adult General ED 68 35.2
only EDs (45.1%). The majority of patients arriving at the hospital Paediatric ED 28 14.5
were first attended to by a Registered Nurse, regardless of whether Adult ED 87 45.1
Other 10 5.2
they arrived by private transport (90.7%) or via ambulance (91.7%).
Most participants had access to a dedicated triage room (76.5%); First staff member attending to wheelchair or walk-in patient
Clerical staff 6 3.1
however, triage was also performed in other areas, including corri- RN 175 90.7
dors, hallways, ambulances, consulting rooms, nurse stations, Physician 24 12.4
wards and temporarily available spaces. The majority of hospitals Other 23 11.9
had one dedicated triage staff member, irrespective of hospital size First staff member attending to ambulance patient
and whether this was during the day shift, evening shift or night Clerical staff 3 1.6
shift. Tables 2 and 3 present the characteristics of the participating RN 176 91.7
Physician 76 39.6
hospitals, including the number of beds and available triage
Other 33 17.1
facilities.
Triage facilities
Just over half (50.8%) of the participants had received dedicated
Designated triage room 143 76.5
triage training prior to commencing their triage role. Of those who Corridor/hallway 82 43.9
received triage training, most reported that the training was pro- Temporarily available space 17 9.1
vided by their employer (38.6%), an education and training organ- Other 14 7.5
isation (30.7%) or at a conference (26.1%). Of those who did not

have any formal triage training prior to undertaking the triage role,
Table 1 most reported that they learnt how to triage through work experi-
Demographic characteristics of survey participants. ence in the ED (80.9%), followed by experience in nursing practice
Age n % (66.7%) and the completion of an in-service triage program pro-
vided by the hospital after commencing their role (61.2%).
20–24 years 27 14.1
25–29 years 76 39.4
Approximately half of the participants reported using formal
30–34 years 51 26.4 triage scales when triaging patients (53.2%). Triage scales used by
35–39 years 25 13.0 nurses were either 4-tier (43%) or 5-tier (34%) scales. Participants
40–44 years 12 6.2 identified four key types of aids that influenced their triage deci-
45 years and over 2 1.0
sions, which included: triage guidelines, work and clinical experi-
Gender ence, decision making trees, and visit flowcharts. Participants
Male 5 2.6
were asked what kind of triage training they believed would be
Female 188 97.4
useful and the majority stated they would prefer to further develop
Educational qualification
their skills through a mentor or more experienced nurse (75.4%),
Diploma 35 18.1
Bachelor Degree 156 80.8 books and other printed material (64.9%) and conferences
Master Degree 2 1.0 (53.8%). There was a degree of variation in the time since partici-
Occupational position title pants last attended triage training. Table 4 details the triage
Junior nurse 48 24.9 requirements at the participating hospitals and the training pro-
Senior nurse 91 47.2 vided to nurses.
Nurse in charge 49 25.4
Associate Professor or Professor 5 2.6
Nursing experience (years) prior to triage role 4. Discussion
No experience 5 2.6
<1 0 0
1–4 76 39.8 The findings of this study highlight a degree of variability in the
5–9 67 35.1 triage practices and associated training of emergency nurses in ter-
10–14 24 12.6 tiary hospitals in Changsha, Hunan Province, China. While the
15–19 12 6.3
majority of participants indicated that their emergency depart-
20–24 7 3.7
ment had at least one staff member allocated to performing triage
Emergency nursing experience (years) prior to triage role
during day and evening shifts, nearly 20% of participants reported
No experience 8 4.2
<1 6 3.2 that no staff were allocated to triage in their emergency depart-
1–4 89 47.6 ment during the night shift. This finding suggests that all nurses
5–9 59 31.6 working during the night shift share the triage workload, meaning
10–14 17 9.1 that inexperienced or under-qualified nurses may be required to
15–19 8 4.3
20–24 3 1.6
triage patients if more experienced staff are busy or unavailable.
While previous studies have suggested that it is common for a
Triage role experience (years)
No experience 26 13.5
number of nurses to work as a team to perform triage, particularly
<1 16 8.3 in situations of uncertainty [13,14], it is generally accepted that at
1–4 97 50.3 least one nurse during any shift is the designated ‘triage nurse’ in
5–9 41 21.2 an emergency department who is responsible for making triage
10–14 9 4.7
decisions [15,16]. Further research is needed to establish whether
>15 4 2.1
the nurses performing triage in this study worked in environments
28 K. Hammad et al. / International Emergency Nursing 35 (2017) 25–29

Table 3
Number of staff typically allocated to triage role, by shift and hospital size.

Number of staff Day shift, 500–1000 Day shift, >1000 Evening shift, 500– Evening shift, >1000 Night shift, 500–1000 Night shift, >1000
allocated to triage bed hospital bed hospital 1000 bed hospital bed hospital bed hospital bed hospital
0 1 0 2 13 7 25
(2.7%) (0%) (5.4%) (9.0%) (18.9%) (17.2%)
1 26 126 29 132 29 120
(70.3%) (85.7%) (78.4%) (91.0%) (78.4%) (82.8%)
2 5 21 5 0 1 0
(13.5%) (14.3%) (13.5%) (0%) (2.7%) (0%)
3 1 0 1 0 0 0
(2.7%) (0%) (2.7%) (0%) (0%) (0%)
4 2 0 0 0 0 0
(5.4%) (0%) (0%) (0%) (0%) (0%)
5 2 0 0 0 0 0
(5.4%) (0%) (0%) (0%) (0%) (0%)

Table 4 commonly used worldwide. This has important implications for

Triage requirements and training.
the accuracy and objectivity of triage practice in China [8]. Triage
How nurses acquired their knowledge prior to performing triage n % scales provide a valid and verified structure and reduce the degree
the first time of subjectivity in the decision-making process [2,14–19]. They sup-
Experience in nursing practice 122 66.7 port nurses to evaluate all the relevant patient information, includ-
Experience in emergency department 148 80.9 ing symptoms, pain severity and required resources, in order to
Completion of an in-service triage education and training 112 61.2
ensure that care is provided according to need. However, the lack
program provided by the hospital
Completion of an accredited triage education and training 76 41.5
of a single evidence-based triage scale that can be used across
program at a provincial level for ED specialist nurses health care venues, highlights the difficulty in adapting triage
Other 6 3.3 scales to different and complex healthcare settings, social contexts
Use of triage scale and funding arrangements [15,16,18,20]. It must be recognised
Yes 97 53.0 that the process of assessing clinical urgency is complex and nurses
No 68 37.2 use a range of strategies that cannot all be replaced by a triage
Don’t know 18 9.8
scale [20].
Type of triage scale used The use of one scale over another was not consistent, meaning
4 tier 43 53.1
that there was a variation in individual triage practices of the
5 tier 34 42.0
6 tier 3 3.7 nurses. This has important implications for the comparability of
7 tier 1 1.2 triage data and the transferability of triage skills across different
Triage training prior to commencing triage role places of employment [2,4,15–18]. Hospitals may not be easily
Yes 92 50.8 comparable with regard to their triage practices and outcomes,
No 89 49.2 which may delay necessary staffing changes and resource alloca-
Triage training provider tion. Furthermore, nurses trained and experienced in using one
Employer 34 38.6 triage scale may need to be retrained when working in a different
Education and training organisation 27 30.7
hospital, which has negative implications for time and cost
Conference 23 26.1
Other 4 4.5
efficiency.
Only half of the survey participants reported receiving formal
Mode of learning how to triage
Mentor/nurse with more experience 129 75.4
triage training, while the majority learnt to triage through their
Book/printed material 111 64.9 nursing experience. For those who did receive triage training, the
Conference 92 53.8 most common providers were their employers, education and
Online course 29 17.0 training organisations and conferences. The different sources of
Other 12 7.1
triage training may be problematic, as it is unclear whether they
Last attendance at triage training are comparable in terms of the quality and comprehensiveness of
Within past week 22 15.6
educational materials and mode of training delivery. The wide
More than a month ago 41 29.1
More than six months ago 33 23.4 variation in the triage scales reportedly used by nurses, suggests
More than 12 months ago 18 12.8 that they are not. The effectiveness of different modes of triage
More than two years ago 27 19.1 training delivery are poorly understood [15,17,20]. For example,
it is possible that triage training delivered at a conference may
be less rigorous and detailed than training provided by a hospital
that facilitated communication and information sharing in order to or a dedicated education and training organisation. Globally, dedi-
make triage decisions, particularly when no staff were allocated cated training programs are routinely delivered to nursing staff
exclusively to triage [14]. with triage responsibilities to reduce subjectivity and errors in
Approximately half of the participants used a recognised triage triage [2,3,15,19]. Training programs vary in their delivery method
scale to guide and inform their triage decisions. Furthermore, there and content, but typically include case-based training that incorpo-
was wide variation in the type of triage scale that nurses used. Just rates written case scenarios, cues such as video footage and pho-
over half of the nurses reported using a 4-tier scale which is in line tographs, and theoretical instruction to support learning
with the national triage guidelines in China. The remainder used [2,6,15,19]. The use of case scenarios allows nurses to apply their
5-, 6- or 7-tier scales, which implies that the national triage guide- theoretical knowledge to simulated clinical practice, which is an
lines are not well adhered to in practice. Furthermore, the use of important first step to applying this knowledge in the fast-paced
scales other than 5-tier is not in line with the triage scales most and often stressful emergency department environment [6,17].
 K. Hammad et al. / International Emergency Nursing 35 (2017) 25–29
Five participants reported having no nursing experience prior to
commencing their triage roles, suggesting that they commenced
their roles shortly after completing their nursing education and
training. Similarly, approximately half of the study participants
reported having less than five years of emergency nursing experi-
ence. This has important implications for patient health and well-
being, given the limited experience these nurses would have in
making decisions about prioritising patients with more urgent
health needs. However, there is conflicting evidence in the litera-
ture with regard to the amount of experience nurses require in
order to accurately perform triage [18]. While it has been sug-
gested that nurses with minimal emergency department experi-
ence can safely and appropriately triage patients as long as they
possess a working understanding of the triage scale used in their
emergency department [18], other studies have argued that inex-
perienced nurses should be required to complete specialised
in-service training before commencing their triage role [13,15–17].
5. Limitations
The findings of this study have limited transferability because
the research was conducted with a relatively small group of emer-
gency nurses from one city in mainland China. For this reason, it is
also difficult to generalise these findings outside mainland China,
particularly in health settings that have a more robust approach
to ED triage. However, the study findings do provide some founda-
tional understanding of triage practice in China, uptake of the
recently implemented national triage guidelines and opportunities
for further improvement of triage practice in China. These findings
need to be considered in light of the fact that the national triage
guidelines were implemented one year prior to data collection. It
is possible that a more structured implementation has occurred
since the conclusion of the study and that emergency nurses are
now more aware of the national triage guidelines. Further research
needs to be undertaken to ascertain the uptake of the national
triage guidelines across mainland China.
6. Conclusion
This paper presented the findings of a study aimed at under-
standing the triage knowledge and practices of emergency nurses
in Changsha, China, following the establishment of national guide-
lines. The study found that despite the establishment of national
triage guidelines in 2012, there remains wide variation in triage
practice. While there is need for further research to establish stron-
ger foundations for the 5-tier triage scales that have tended to be
utilised internationally, it is interesting to note that the national
guideline recommends a customised 4-tier scale. Furthermore, this
research highlighted a wide variation in the experience, education
and training completed by emergency nurses prior to undertaking
their triage role. The national guidance recommends at least five
years of experience and it is clear that many health facilities are
moving toward that goal; however, approximately half of the
cohort studied had less than five years of experience when they
undertook triage. This variation within a local context suggests
that the national guidelines have been slow to impact healthcare
settings. This may have an effect on the training and retraining
required for health staff and potentially lead to confusion concern-
ing triage scales both across and within individual healthcare set-
tings. This study highlights the need for a more structured
approach to triage practice in order to ensure consistency across
hospitals and, potentially, enhance patient outcomes.
29
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical statement
Informed consent was obtained from study participants. The
privacy rights of participants were observed at all times.
Funding source
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Acknowledgements
The authors wish to thank Huahua Yin for her contribution to
the translation of questionnaire responses and Imogen Ramsey
and Constance Brett for their contribution to quantitative and qual-
itative data analysis.
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