International Emergency Nursing (2013) 21, 113– 117

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REVIEW

Using a theory to understand triage decision making

Maternal Child Nursing Department, University of South Alabama, College of Nursing, Mobile, AL, United States

Received 21 December 2011; received in revised form 5 March 2012; accepted 7 March 2012

KEYWORDS Abstract
Triage decision-making; The purpose of this discussion is to present triage decision making research within the context
Revised Cognitive Contin-
of the Revised Cognitive Continuum Theory. Triage is an essential clinical skill in emergency
uum;
nursing. Understanding the best way to facilitate this skill is vital when educating new nurses
Intuitive judgment;
Reflective judgment; or providing continuing education to practicing nurses. Delineating research evidence within
Systems-aided judgment a theory allows clinical educators to understand practices that foster successful triage skills
and permits the grounding of educational strategies within a theoretical framework.
ª 2012 Elsevier Ltd. All rights reserved.

Introduction Revised Cognitive Continuum Theory

Examining the triage decision-making research and under- Hammond’s Cognitive Continuum Theory (Hammond, 1988,
standing what influences triage proficiency and accuracy is 1996, 2000) embraces the various explanations of decision
significant to emergency nursing. Appropriate facilitation making detailed in the nursing literature. In this theory,
of triage decision making is crucial when educating new judgments and tasks are linked to cognition. Decision mak-
graduates or providing continuing education to practicing ing is based on six broad modes of inquiry which exist on a
nurses transferring into an emergency setting. A review of continuum, with intuitive judgment at one end and scien-
the triage literature demonstrates a focus on decision mak- tific thinking (analysis) at the other end. The six cognitive
ing within Emergency Departments (EDs), with research modes are: scientific experiment mode, controlled trials
samples composed primarily of experienced ED nurses. mode, quasi experimental mode, systems-aided mode,
The purpose of this discussion paper is to present exemplars peer-aided judgment, and intuitive judgment mode (Hamm,
of triage decision-making evidence within the context of the 1988). The decision making is influenced by task character-
Revised Cognitive Continuum Theory (Standing, 2008). An istics which can be well structured or ill structured and by
established decision-making/cognitive theory provides a potential for manipulation and time (Harbison, 2001).
lens to frame and synthesize the triage evidence and allows Numerous theoretical discussions of the Cognitive Contin-
educators to identify pedagogies that specifically foster tri- uum Theory can be found among nurse scholars (Cader et
age decision making. al., 2005; Harbison, 2001; Standing, 2008). Harbison
(2001) in her discussion of decision making advocates the
use of the Cognitive Continuum because it does not justify
E-mail address: anitasmith@usouthal.edu one type of approach to decision making.

1755-599X/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ienj.2012.03.003
114 A. Smith

Cader et al. (2005) analyzed and evaluated the Cognitive conscious awareness of how a judgment is made is associ-
Continuum Theory using the criteria identified by Fawcett’s ated within the patient- and peer-aided mode of practice.
framework and classified the theory as a mid-range descrip- Patients and peers contribute information, participate in
tive theory; it is a theory that focuses on judgment and decision making, and provide data that contributes to pa-
decision making and provides a framework for concepts of tient care. Assessment tools, clinical guidelines, and policy
task (ill-structured to well-structured tasks) and cognition and procedures define the systems-aided judgment mode of
(analysis to intuition) (Cader et al., 2005). The intuitive cog- practice. Finally, reflective judgment is the involvement of
nitive process is used for ill-structured tasks, while the anal- reflecting on actions and past experiences and using this
ysis mode is used for well-structured tasks. This is important knowledge. These modes of practice are not listed in a hier-
to note, as triaging happens in both structured and unstruc- archal order. Judgment is fluid and flexible and a triage
tured manners. The Cognitive Continuum Theory is used by nurse will use various modes while assessing and providing
many disciplines to explain decision making and has poten- patient care.
tial to contribute to the understanding of clinical decision Framing the triage decision making evidence within the
making among triage nurses (Cader et al., 2005). Revised Cognitive Continuum Theory with emphasis on four
Standing (2008) suggests a revised version of the Cogni- of the modes of practice highlights the different ways triage
tive Continuum Theory and offers it as an educational tool decision making takes place in the emergency setting. In
and practice guide in promoting decision making among addition, the delineation of modes of practice used in triag-
nurses. The six modes of inquiry found in the Cognitive Con- ing within a theoretical framework permits clinical educa-
tinuum Theory are increased and renamed as nine modes of tors/staff developers to identify appropriate education
practice. The modes of practice are not listed in numerical strategies that facilitate triage decision making.
order, as Hammond’s six cognitive modes of inquiry are. By
not placing modes of practice in numerical order, Standing
(2008) emphasizes the flexibility of cognition along the con- Triage decision making evidence supporting
tinuum and that judgment tasks are constantly changing. In Standing’s four modes of practice
the revised continuum, sources of knowledge range from
intuition to analysis, and the nine modes of practice in- A Pub Med search was conducted using the words ‘‘triage,’’
clude: intuitive judgment, reflective judgment, patient- ‘‘decision making,’’ and ‘‘nursing,’’ which yielded 145 arti-
and peer-aided judgment, system-aided judgment, critical cles written between 1972 and 2010. Articles written in Eng-
review of experimental and research evidence, action re- lish and focusing on triaging by nurses in the Emergency
search and clinical audit, qualitative research, survey re- Department were included. Non English articles and those
search, and experimental research (Standing, 2008). focusing on telephone triage were excluded. Two general
Table 1 lists the nine modes of practice outlined in the themes emerged in reviewing the triage decision-making lit-
Revised Cognitive Continuum (Standing, 2008). The Revised erature, which can be broadly identified as (a) use of triage
Cognitive Continuum model allows triage nurses to visualize and acuity tools and (b) personal characteristics of the deci-
the judgment skills needed in patient assessments and can sion maker. These themes are reflective of the modes of
be used as a learning tool or practice guide in fostering practice identified in the Revised Cognitive Continuum The-
the decision-making skills for novice and practicing nurses. ory in that using the established triage tools represents the
Specifically four of the modes of practice (system aided use of system-aided judgment (analysis and guidelines), and
judgment, patient- and peer-aided judgment, reflective the personal characteristics identified in research studies
judgment, and intuitive judgment) are applicable to the reflect the use of intuitive judgment, peer and patient aided
decisions triage nurses make daily. The focus of this discus- judgment, and reflective judgment.
sion is on these four modes of practice.
Standing (2008) briefly defines the modes of practice
within the context of nursing. Intuitive judgment is coming System-aided judgment
to judgments without being aware of the process, while
A central theme in the review of the triage decision making
research is use of triage tools in the emergency setting.
Table 1 Nine modes of practice of the revised cognitive Established triage tools are reflective of system-aided judg-
continuum. ment as the triage nurse is answering questions grounded in
established triage guidelines. System-aided judgment is re-
Revised Cognitive Continuum Theory nine modes of
flected in the studies outlining and evaluating the use of a
practice (Standing, 2008)
five-level triage algorithm (Beveridge et al., 1999; Wuerz
Experimental research et al., 2000; Murray et al., 2004; Bullard et al., 2008). The
Survey research use of algorithms, severity indexes, and electronic triage
Qualitative research tools represent specific guidelines for triaging patients in
Action research and clinical audit either an adult or pediatric emergency setting and demon-
Critical review of experimental and research evidence strate the use of systems-aided judgment. Only a few of
System aided judgment the available triage tools are summarized in this discussion.
Patient and peer aided judgment The Emergency Severity Index (ESI) and the Canadian
Reflective judgment Triage and Acuity Scale (CTAS) are five-level triage
Intuitive judgment instruments. The ESI was developed and validated in a sam-
ple of 493 patients in order to determine clinical resources
Using a theory to understand triage decision making 115

and hospitalization needs (Wuerz et al., 2000). The focus of decision making and the making of probability judgments.
the triage tool is based on both (a) when to see a patient The concept of relying on past clinical experiences in mak-
and (b) what resources are needed by the patient. The algo- ing decisions in uncertainty is further developed in inter-
rithm of placing the patient in one of five categories is based views with 32 expert nurses from wards in a teaching
on physiological data, thus it is a guide that promotes use of hospital in Australia. Cioffi (2001) found that 63% percent
system aided judgment by the nurse. of the nurses voiced that they used past experiences in their
The Canadian Emergency Department Triage and Acuity decision-making processes. Cioffi (2001) recommends expo-
Scale (CTAS) was developed and implemented across Canada sure to various clinical experiences in order to facilitate
in the late 1990s; it is a five-level triage scale that allows a triage decision making. Experience and use of prior experi-
provider to classify patient acuity based on presenting com- ences is reflective of intuitive judgment and reflective judg-
plaint (Beveridge et al., 1999; Murray et al., 2004; Bullard ment. Providing exposure to various clinical experiences can
et al., 2008). Evidence examining the reliability and inter- be provided by hospital educators to facilitate decision
rater agreement of scores was favorable (Bullard et al., making among novice nurses.
2008). With the original CTAS guidelines, there were limited Tippins (2005) noted pattern recognition, interpreting
numbers of presenting complaints, thus the triage score physiological signs and symptoms, and use of intuition as
could be subjective if a complaint was not listed in the guide- characteristics of the decision maker. An exploratory meth-
line. Based on feedback, several revisions to this triage tool odology was used to examine emergency department
occurred over the years (Murray et al., 2004; Bullard et al., nurses’ ability to recognize and manage patient deteriora-
2008). The updates include more physiological data and tion. Data were collected from a sample of 23 British emer-
modifiers for accurately identifying acuity level and are gency nurses working with a two-part questionnaire and a
reflective of system aided judgment. semi-structured interview. Experience was influential in
While the triage acuity scales demonstrate reliability and early identification of patient deterioration and nursing re-
validity in various samples of emergency department pa- sponse. This experience could be general, positive, or neg-
tients, the focus of the guidelines are on the physiological ative. Identification of physiological signs and symptoms and
systems exhibited, the time to see provider, and the re- intuition seemed to be used in tandem and demonstrated
sources needed. These acuity/triage tools provide guide- the use of reflective judgment. For example, a patient’s
lines to determine the critical nature of a patient and are mental status score is within normal limits, but there are
reflective of system-aided judgments. Accuracy and consis- other cues that suggest the patient is ‘‘just not right’’.
tency of triage decision making in the emergency depart- Hicks et al. (2003) used a correlational design and a sam-
ment is fostered by using such instrumentation. The ple of 54 critical care nurses working in three private hospi-
concept of using a tool or guideline to assist in assessing tals in the United States to examine the relationship of
physiological symptoms can be helpful, especially for new education level, years of critical care experience, and crit-
nurses or experienced nurses new to triaging in the emer- ical thinking skills to the consistency of clinical decision
gency setting. With the universal use of computerized making. Critical thinking was not linked to education or
charting and hand-held computer devices/phones, the use experience, but decision-making consistency was linked to
of guidelines is easier to implement and can assist with sys- having more years of experience. The authors recom-
tem-aided triaging. mended providing more clinical experiences for nurses be-
cause various experiences, rather than skill level,
influenced decision making. Experience lays the foundation
Intuitive and reflective judgment for future decision making in that nurses can reflect on it
when encountering new situations.
The personal characteristics of the nurse are detailed Experience and intuition use is a strong, continuous theme
extensively in the triage decision making studies (Andersson in the triage decision-making research among samples of
et al., 2006; Cioffi, 1998; Cioffi, 2001; Chung, 2005; Hicks nurses from multiple continents. Andersson et al. (2006)
et al., 2003; Patel et al., 2008; Tippins, 2005). Nursing expe- identified experience level, knowledge, and intuition as skills
rience, pattern recognition, subjective factors, risk taking, needed for triaging decision making through an observational
and judging are characteristics identified in the review of study. The researchers observed and interviewed a sample of
triage decision-making research and are reflective of intui- 19 emergency department nurses in rural Sweden to deter-
tive, patient and peer, and reflective judgment. mine how nurses triage patients. The interview allowed
Experience is an essential characteristic repeatedly iden- nurses to describe how they decided to prioritize patient
tified and this clinical experience does not necessarily need care. Through qualitative content analysis, the categories
to be in the emergency department setting. Cioffi (1998, of skills, personal capacity, work environment, and assess-
2001) examined decision making in uncertainty and emer- ment were identified as explaining triage decision making.
gent situations, as well as in the use of heuristics among Skills included experience, knowledge, and intuition, which
nurses with various experience levels. Heuristics is de- allow for use of intuitive and reflective judgment.
scribed as strategies to make inferences that are influenced Another observational study was conducted by Gerdtz
by past experiences. The foci of Cioffi’s exploratory and and Bucknall (2001) that also reflected the use of intuitive
descriptive studies were on how decisions were made in and reflective judgment. The aims of this structured obser-
the uncertain situation. In a descriptive approach, Cioffi vation study were to (a) describe decision making of triage
(1998) found that nurses, especially the experienced nurses, nurses and (b) describe data collected to prioritize care.
made more probability-based judgments (heuristics). A The sample of 26 nurses was drawn from adult emergency
bank of experiences or prior clinical experiences influenced departments in metropolitan Melbourne, Australia. An
116 A. Smith

interesting finding from the observations was the number of System aided, intuitive, patient and peer aided, and reflec-
triage decisions made without physiological data, vital tive judgments styles are illustrated within samples of expe-
signs, or neurological assessments. rienced ED nurses. A strong emphasis is placed on the use of
Through unstructured interviews and qualitative analysis triage tools that access physiological symptoms, but signif-
with seven emergency room nurses in Hong Kong, Chung icant evidence exists demonstrating the importance and
(2005) identified the use of (a) experience, (b) established influence of the nurse’s personal characteristics (education
triage guidelines, and (c) intuition as information used in tri- preparation, use of intuition, and years of experience).
age decision making. The sample of nurses had 5–11 years of These personal characteristics highlight the use of intuitive
emergency nursing experience. The nurses viewed triage judgment, reflective judgment, and patient- and peer-
guidelines as a reference and, at times, inflexible. Experi- aided judgment. In the theoretical discussions of decision
ence fostered alertness in the nurses, and use of intuition making, no one decision model is advocated but a combina-
was described as use of subjective factors. Information from tion of cognitive or judgment strategies (Harbison, 2001;
pre-hospital personnel and the patients was also identified Standing, 2008). This is also evident in the review of triage
as information used in making triage decisions, which is decision-making research as various modes of practice are
reflective of patient- and peer-aided judgment. Using ethno- identified among experienced nurses making triage deci-
graphic observation and semi-structured interviews, Patel sions. A limitation of this discussion is that literature was
et al. (2008) investigated the process of triage and the utili- only reviewed from PubMed.
zation of guidelines in a Canadian pediatric emergency
department. Triage decisions were based on non-analytic
processes, and intuition and triage guidelines were used dif-
Implications for emergency nursing
ferently by the nurses.
In summary, use of intuitive judgment by emergency The evidence generated from the review of the triage deci-
nurses is predominant in the identified qualitative research sion-making literature can influence the development and
studies, and inconsistent use of triage tools (systems-aided implementation of training programs that foster triage deci-
judgment) is common among the experienced nurses. Prior sion making. By outlining the triage decision-making evi-
experience allowed nurses to use reflective judgment skills. dence within the Revised Cognitive Continuum, pedagogies
or educational strategies that foster successful triage skills
Patient and peer aided judgment among emergency nurses can be identified, developed, and
implemented. The educational strategies should emphasize
the four modes of judgment outlined in the research litera-
Edward’s and Sines’ (2007) qualitative study implementing a
ture. For example, rotating a novice nurse through various
grounded-theory/symbolic integrationist methodology high-
clinical settings builds a repertoire of experiences that
lights use of patient-aided judgment in a sample of 14 emer-
can be used in triage decision making. Experienced nurses
gency nurses working in United Kingdom hospitals. The
who work in medical surgical, critical care, or maternal
intent of researchers was to develop a grounded theory
child settings bring a wealth of experience when transfer-
depicting how nurses act and think during the initial assess-
ring to the emergency setting. Diverse clinical experiences
ment of triage. The reported findings focused on the main
facilitate the practice modes of intuitive, reflective, and
condition within triage, which was identified as ‘‘appraising
patient and peer aided judgments.
client credibility’’. Assessment was based on the client’s
Use of human patient simulation is a promising educa-
appearance and description of issue, because the ‘‘look’’
tional strategy as it provides clinical experiences and the
of patient was a vital detail. The triage nurses acted as an
opportunity to dialog with peers and families. It is a staged
arbitrate panel, judging the data provided by the client.
scenario that results in no harm to the patient. Simulation
This implied that the client was an active participant in
provides a means to implement the four modes of practice
the assessment and interpretation of the problem (Edwards
that facilitate triage decision making skills in a safe
and Sines, 2007). McBrien (2009) describes the implementa-
environment.
tion of a person-centered triage training program for nurses
The triage tools provide guidelines for triaging care,
in an Irish emergency department. Patient centered care is
which is useful for the novice nurse. While system-aided
grounded on the fact that the patient contributes informa-
judgment can be promoted among novice nurses who have
tion and experience to the triage encounter and is focused
limited clinical experience, the emphasis for the experi-
on a holistic model of care versus a medical model of care.
enced nurse can be on the decision maker’s characteristics,
This approach is reflective of using patient-aided judgment.
experience level, and use of intuition. Other factors to con-
sider when implementing triage educational programs,
Summary aside from the nurse’s characteristics and experience level
include (a) the nursing topic and (b) learning style of the
To improve nursing practice, particularly the triaging of pa- nurse. Just as Standing (2008) outlines various practice
tients in the emergency setting, it is vital to review the re- modes with no hierarchal leveling, one must consider a con-
search evidence. By presenting the published evidence tinuum of educational strategies or pedagogies in promoting
within a theoretical model, it allows educators to focus on triage decision making. Fostering triage decision making can
educational strategies that foster triage decision making be via multiple strategies that capitalize on the characteris-
judgments. In this discussion, the triage decision making tics of the nurse. The research evidence also demonstrates
evidence reflected four of the practice modes outlined in the use of multiple modes of practice used in triage decision
the Revised Cognitive Continuum Theory (Standing, 2008). making among experienced emergency nurses. Future
Using a theory to understand triage decision making 117

research needs to include studies that focus on evaluation Cioffi, J., 1998. Decision making by emergency nurses in triage
of educational strategies that foster the various types of assessment. Accid. Emerg. Nurs. 6, 184–191.
judgments used in triage decision making. Cioffi, J., 2001. A study of the use of past experiences in clinical
decision making in emergency situation. Int. J. Nurs. Stud. 38,
591–599.
Conclusion Edwards, B., Sines, D., 2007. Passing the audition – the appraisal of
client credibility and assessment by nurses at triage. J. Clin.
Examining the triage decision-making research within the Nurs. 17, 2444–2451.
Revised Cognitive Continuum Theory provides a framework Gerdtz, M.F., Bucknall, T.K., 2001. Triage nurses’ clinical decision
for identifying the modes of practice and judgment used in making. An observational study of urgency assessment. J. Adv.
triage decision making. Understanding the modes of prac- Nurs. 35 (4), 550–561.
Hamm, R.M., 1988. Clinical intuition and clinical analysis expertise
tice used in triaging, which include system aided, intuitive,
and the cognitive continuum. In: Dowie, J., Elstein, A. (Eds.),
reflective, and patient and peer assisted judgments, assists Professional Judgment: A Reader in Clinical Decision Making.
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are outlined in the triage decision making research. The ducible Uncertainty, Inevitable Error. Oxford University Press,
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ential in triage decision making. Emphasizing all modes of Hammond, K.R., 2000. Judgment Under Stress. Oxford University
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Harbison, J., 2001. Clinical decision making in nursing: theoretical
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