International Emergency Nursing 51 (2020) 100889

Contents lists available at ScienceDirect

International Emergency Nursing

journal homepage: www.elsevier.com/locate/aaen

The impact of adult trauma triage training on decision-making skills and T

accuracy of triage decision at emergency departments in Malaysia: A
randomized control trial
Siti Aishah Ghazalia,b,⁎, Khatijah Lim Abdullahb, Foong Ming Moyc, Rashidi Ahmadd,
Emni Omar Daw Hussinb
a
School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kelantan, Malaysia
b
Department of Nursing Science, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
c
Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
d
Department of Emergency Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia

ARTICLE INFO ABSTRACT

Keywords: Introduction: Patients who visit emergency departments need to undergo a precise assessment to determine their
Accurate priority and accurate triage category to ensure they receive the right treatment.
Decision Aim: To identify the effect of triage training on the skills and accuracy of triage decisions for adult trauma
Skills patients.
Triage
Method: A randomized controlled trial design was conducted in ten emergency department of public hospitals. A
Emergency department
total of 143 registered nurses and medical officer assistants who performed triage roles were recruited for the
Registered nurses
Medical officer assistants control group (n = 74) and the intervention group (n = 69). The skill and accuracy of triage decisions were
Triage training measured two weeks and four weeks after the intervention group were exposed to the intervention.
Results: There was a significant effect on the skill of triage decision-making between the control and the in-
tervention group p < 0.001, η2 partial = 0.31. Concerning the accuracy of triage decisions, the effect was sig-
nificantly different between the control group and the intervention group p < 0.001, η2 partial = 0.66 across
time.
Conclusion: The triage training improved the skills of the participants and the accuracy of triage decision-making
across time.

1. Introduction knowledgeable and skillful RNs and MOAs are crucial to determine
accurate triage decisions. Therefore, the current study is conducted to
The emergency department (ED) is a “front door” facility that pro- identify the skills and accuracy of triage decision-making for adult
vides critical care in hospitals. Patients admitted to EDs require highly trauma patients in EDs and to assess the effect of triage training on the
time-sensitive emergency treatment and need immediate intervention skills and accuracy of triage decision-making among RNs and MOAs in
[1]. Initially, a patient needs to go through a triage process by regis- Malaysia.
tered nurses (RNs) or medical officer assistants (MOAs) to determine
the triage category according to the severity of the patient’s condition. 2. Literature
MOAs who are paramedics, and RNs, both of whom complete 3 years of
training, are qualified to perform triage roles at the scene as well as in Triage is one of the core requirements for the provision of effective
the ED. In the EDs, the triage system is divided into three categories: emergency care and has been shown to reduce patient mortality [3].
category 1-critical; 2-high risk; 3-non-critical [2]. In prioritizing a pa- The primary aim of triage is to identify patients who can safely wait
tient’s urgency for an accurate triage category in adult patients, espe- from those who cannot. The secondary aim is to ensure that patients
cially for trauma, skillful RNs and MOAs are essential to ascertain the receive safe treatment within a certain time frame [4]. Triage staff
best impact of intervention on the patient’s health. Hence, decide and allocate patient urgency for treatment and care into

Corresponding author at: School of Health Sciences, Health Campus, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.
⁎

E-mail addresses: schah@usm.my, ai_shah66@yahoo.com (S.A. Ghazali), katlim@um.edu.my (K.L. Abdullah), moyfm@ummc.edu.my (F.M. Moy),
rashidi@ummc.edu.my (R. Ahmad).

https://doi.org/10.1016/j.ienj.2020.100889
Received 7 April 2019; Received in revised form 28 April 2020; Accepted 12 May 2020
1755-599X/ © 2020 Elsevier Ltd. All rights reserved.
S.A. Ghazali, et al. International Emergency Nursing 51 (2020) 100889

emergent, urgent, and non-urgent, according to the patient’s condition critical thinking (12 items) for the purpose of evaluating triage deci-
and the priority of care required to ensure that the patient receives the sion-making skill among ED staff. The summative score for the whole
appropriate treatment. According to Horne, Vassallo, Read, and Ball TDMI instrument is 222. The cut-off point for low score is below 184.
[5], triage is the process of sorting critically ill patients who need im- PSBQs were developed for the purpose of measuring accuracy of triage
mediate life-saving interventions from patients who need medical at- decisions. The PSBQs have 15 questions with 5 PSBQs for each of the
tention but can safely wait to be seen. Accurate triage decisions have a triage categories (red color code: critical; yellow color code: high risk
positive impact on the emergency department with reduced waiting and Green color code: non-critical). Scores lower than 12 were con-
times and improved management of patients [6]. Whereas, inaccurate sidered ‘low’. The reliability and validity of both instruments were ex-
triage decisions can have many undesirable consequences when ap- amined. The test–retest results for the intra-class co-relation coefficient
propriate intervention and care are not delivered timely, such as de- scores show excellent value 0.95, 95% CI = 0.90–0.96 and Cronbach’s
terioration of condition, long waiting hours, and misuse of resources Alpha 0.97 for the entire instrument of TDMI, while 15 out of 30 PSBQs
[7], as well as causing dissatisfaction and bad impressions of the ED with k values ranging from good to excellent were selected for current
service and nursing professionalism. Furthermore, unskillful personnel study. The questionnaires were reviewed by 12 experts for content
and inaccurate triage decisions lead to a waste of resources, delays in validity, and 46 RNs and MOAs who are in the emergency field to de-
patients’ treatment, dissatisfaction, and undesirable consequences [8]. termine the reliability of the TDMI and PSBQs. Changes were made
Therefore, a skillful triage officer should be at the triage desk to per- according to their recommendation. For example,‘I can count on my
form triage tasks as necessary. skills and judgement while working at triage’, the word ‘count’ was
changed to ‘rely’ and ‘I associate the mechanism of injury with the
3. Method history given by the patient at triage’ the word ‘associate’ was changed
to ‘relate’.
3.1. Design and setting

A stratified randomized control trial was conducted in the EDs of ten 3.3. Ethical considerations
hospitals in North Penisular of West Malaysia from 2015 to 2016. The
RNs and MOAs who underwent at least three years of training at a Ethical approval was sought from the Research Registry (NMRR-13-
healthcare institution and had previous experience in performing triage 1477-16716) and Ethics Committee (Human) Universiti Sains Malaysia,
roles were included in this study. A total of 274 RNs and MOAs who Health Campus (JEPeM USM code: USM/JEPeM/[282.3(7)] and
fulfilled the criteria were invited to participate in the study. Current Universiti Malaya Medical Centre (Ethic Committee Reference
study comprised two phases: Phase 1 was a cross-sectional baseline Number/IRB: 1031.1). Written informed consent was obtained from
study that provided pre-test data on 202 participants recruited from ten each participant prior to the study.
EDs using universal sampling, who returned the questionnaires that
giving 73.73% of response rate. Hospital with participants who ob-
tained low score for skill, were invited to enroll in phase 2. Phase 2 was 3.4. Intervention and application
an interventional study, using a randomized controlled trial design. An
effect size formula by Kadam and Bhalerao [9] was used for sample size The intervention in this study was in the form of triage training. The
estimation and 143 participants of the ten hospitals who scored low for module’s development was based on the results of the baseline study,
skill were randomly allocated to a control and an intervention group literature reviews, and Knowles’ theory. The suggestions of the RNs and
using balloting method with ratio 1:1. The hospitals were stratified to MOAs about aspects they required as preparation prior to performing
specialist and non-specialist hospitals. Hospitals’ name were written on the triage roles were taken into account as a source for the development
pieces of paper and placed accordingly into the specialist hospitals’ and of the program. The purpose of the intervention was to increase the
non-specialist hospitals’ boxes. The hospitals were selected by drawing skills and accuracy of the triage decisions by the RNs and MOAs. The
the paper, one-by-one, from the two boxes and were placed, alternately, training took the form of lectures, discussions and performing triage
into containers labeled one (1) which is intervention group and two (2) using scenario-based questions in group, which were conducted in
for control group. Selection of hospitals into either the intervention or 140 min in each hospital and completed in one session.
the control group was carried out by a neutral person, who had no
interest in the study. The intervention group (69 participants) of five
EDs was exposed to the triage training, while no intervention was 3.5. Data analysis
provided to the participants of the five EDs in the control group (74
participants). After the intervention group was exposed to the triage The data were entered and analyzed using the Statistical Package for
training intervention, the skill and accuracy of triage decisions for both the Social Sciences (SPSS) version 20. Descriptive statistics were re-
groups were measured in the post-test and follow-up test which com- ported using the mean, standard deviation, and frequency for the de-
prised of the original number of participants of the hospitals assigned in mographic characteristics and study variables. A t-test and chi square
the both groups for both measurements. were applied to compare the demographic characteristics between the
control group and the intervention group; means comparison between
3.2. Instrument RNs and MOAs; and TDMI and PSBQs score at baseline, post-test, and
follow-up for both groups. A General Linear Model Repeated Measures
The Triage Decision Making Inventory (TDMI) and Patient Scenario- (RM) ANCOVA followed by the Bonferroni test for mean comparison
based Questions (PSBQs) of adult trauma (AT) were used respectively between the intervention group and the control group at pre-test, post-
for both phases. TDMI was developed by Cone [10] with good validity test, and follow-up were performed accordingly. Demographic char-
and reliability to examine skill of triage decision making among nurses acteristics, t-test, and chi square with p < 0.05 were considered as
and was used for the same purposes by Cone and Murray [11] and covariates in RM ANCOVA. Partial eta square (η2) was used to test the
Smith and Cone [12]. Whilst many studies used PSBQs to evaluate efficacy of the triage training and the difference between the accuracy
accuracy of triage decision among ED staff ([4,13,14]). The TDMI tool of triage decisions and the TDMI scores before and after exposure to the
comprises 37 questions. It has four domains with six Likert scales, from intervention. All the assumptions for RM ANCOVA were met.
strongly disagree to strongly agree. The items focus on the cognitive
characteristics (7 items), experience (11 items), intuitive (7 items), and

2
S.A. Ghazali, et al. International Emergency Nursing 51 (2020) 100889

4. Results follow-up compared to the control group; Table 3.

While the results of the Pairwise Comparison for the PSBQs de-
4.1. Baseline study monstrated a significant difference in the PSBQ mean scores between
the intervention group and the control group at the post-test and the
4.1.1. Demographic characteristics follow up (p < 0.001). The results of the mean comparisons between
The results demonstrated that more than half (n = 133, 65.86%) of the three tests over time for the control group and the intervention
the participants were male, and aged between 30 and 35 years, with a group indicate that there was a significant mean difference between the
mean age of 35.71 years (SD = 7.42). Nearly two-thirds of the parti- pre-test, post-test, and follow-up test (p < 0.001); Table 4.
cipants were medical officer assistants (n = 129, 63.86%) with the rest
being registered nurses (n = 73, 36.14%). The majority were diploma 4.2.3. TDMI and PSBQs score between RNs and MOAs
holders (n = 189, 93.6%). More than three-quarters of the participants A comparison of the scores between the RNs and MOAs at baseline
(n = 152, 75.2%) did not have any emergency post basic training. indicated the TDMI mean score for RNs (M = 179.57, SD = 11.72) and
Majority of RNs and MOAs have had 6 years and above of ED working MOAs (M = 179.53, SD = 18.58), while the mean score for the PSBQs
experience: the mean length of working experience in the ED was for RNs (M = 10.71, SD = 1.60) and MOAs (M = 10.71, SD = 1.85)
7.58 years (SD = 5.62), More than half (n = 120, 59.4%) had less than were not significantly different, p = 0.99 and p = 0.08, respectively.
6 years triage experience; the mean length of triage experience was The TDMI and PSBQ scores between the RNs and MOAs at post-test
5.63 years (SD = 4.94). were significantly different, p = 0.02 for both. Whilst, at follow-up, the
results indicated that there was no significant difference in the TDMI
4.1.2. Level of TDMI and PSBQs score between the RNs and MOAs, p = 0.37. However, there was a
The baseline results indicated that 29.2% (n = 59) of the partici- significant difference between them for the PSBQ score, P = 0.03;
pants had a high level of TDMI (184 or higher), while the remaining Table 5.
70.8% (n = 143) had a low score. The majority of the participants
(n = 141, 69.8%) had low scores for PSBQs; Table 1. 5. Discussion

4.2. Intervention study There are significant differences between the number of RN’s and
MOA’s between the control and intervention groups due to the staffing
4.2.1. Demographic characteristics control and intervention group allocation in some of the hospitals. However the demographic char-
Table 2 demonstrates that there was no significant difference be- acteristic of the participants for both groups was similar. In addition
tween the two groups, except for designation and attending continuous both designations were controlled by computing them as covariate
professional education (CPE), which showed a statistically significant factor. The result showed that the difference between MOAs and RNs
difference between the two groups. The t-test showed that the TDMI at did not affect the current results, which indicate the intervention still
baseline was significantly different between the control group and the had positive impact regardless of difference.
intervention group, thus, the designation, CPE, and TDMI at baseline, Nevertheless this disparity was not generally represent the dis-
were used as covariates for all the analyses; Table 2. tribution of MOAs and RNs in ED hospitals in Malaysia. Finding of the
study also indicated that RNs and MOAs obtained a ‘low’ score for the
skill and accuracy of triage decisions at baseline; one possible ex-
4.2.2. Effectiveness of triage training on the skill and accuracy of triage
planation is that the majority of them were not well trained and had not
decisions
obtained their post basic in emergency prior to commencing their triage
The results showed a significant difference in the TDMI scores be-
role. They obtained their triage experience on the job training. This is
tween the control group and the intervention group (p < 0.001, η2
supported by the findings of the demographic characteristics, which
partial = 0.31). The mean difference was 23.26 (CI:17.36, 29.16). While
demonstrated that more than three quarters of them do not have post
for the PSBQ scores, there was a significant difference in the scores
basic emergency training. A conducive environment was one of the
between the control group and the intervention group (p < 0.001, η2
factors that may induce learning and clinical reasoning among nurses in
partial = 0.66). The mean difference was 3.02 (CI: 2.66, 3.39). These
the clinical area [15]. Overwork, tiredness, and the lack of any break in
results indicated that by controlling the covariate factors, such as des-
the unpredictable and demanding ED environment may have lowered
ignation, CPE, and TDMI at the pre-test, the intervention had a positive
the nurses’ skill and ability to make accurate triage decisions [16]. In
impact on the TDMI and PSBQ scores regardless of time. A Pairwise
addition, a lack of knowledge, lack of experience, anxiety and en-
Comparison for TDMI resulted in a significant difference in the TDMI
vironmental barriers, such as changing situation, may reduce their skill
mean score between the intervention group and the control group at the
to make accurate triage decisions over time [17].
post-test and follow-up (p < 0.001). Furthermore, there was only a
Unskillful and inaccurate triage decisions have several negative
difference in the mean score for the TDMI between the post-test and
impacts and can jeopardize patients’ health. Thus, an appropriate
follow-up for the intervention group (p < 0.001). These results reveal
measure needs to be undertaken to improve their skill and accuracy in
that the intervention group had higher TDMI scores at the post-test and
making accurate triage decisions. The skill and accuracy of the triage
decision results show that they require training rather than need ex-
Table 1
perience to improve their skill in triage decisions since more than half
Frequency Distribution of the TDMI and PSBQs among RNs and MOAs
(n = 202) at Baseline. of them have 6 years and above working experience in EDs. A previous
study reported that an educational platform and training on triage in
Variables Level Frequency (n) Percentage (%) Mean SD the emergency department is important in order to improve the triage
TDMI 175.00 20.21 decision-making skills of the ED staff [18]. The findings of the current
Low 143 70.8 study demonstrated that after exposure to the triage training, both the
High 59 29.2 skill and accuracy in triage decision-making among the RNs and MOAs
PSBQs improved, revealing that the structured triage training was significantly
Low 141 69.8 10.52 1.71
High 61 30.2
effective. Vigorous discussion on the various complaints and assessment
of a patient on arrival to the ED using PSBQs have enlightened and
PSBQs: patient scenario base questions; TDMI: Triage decision making in- enhanced their knowledge and critical thinking, and, thus, improved
ventory; RNs Registered nurses; MOAs Medical officer assistants. their skill and accuracy in triage decision-making. A previous study by

3
S.A. Ghazali, et al. International Emergency Nursing 51 (2020) 100889

Table 2
Demographic Characteristics: Comparison of Control and Intervention Groups.
Variables Level Control Group Intervention group χ2 P-value

n = 74 % n = 69 %

Gender Female 18 40.9 26 59.1 2.99 0.10

Male 56 56.6 46 43.4
Age Groups (years) ≤30–35 yrs 32 49.2 33 50.8 3.22 0.20
36–40 yrs 29 61.7 18 38.3
≥41 yrs 13 41.9 18 58.1
Designation RN 16 32.7 33 67.3 10.88 0.001
MOA 58 61.7 36 38.3
Post Basic Emergency 37 55.2 30 44.8 0.61 0.50
NO 37 48.7 39 51.3
ED working Experience ≤5 yrs 27 55.1 22 44.9 1.87 0.40
6–10yrs 20 43.5 26 56.5
≥11 yrs 27 56.2 21 43.
Triage Experiences ≤5 yrs 31 48.4 33 51.6 2.96 0.24
6–10yrs 29 61.7 18 38.3
≥11 yrs 14 43.8 18 56.2
Attend CPE YES 37 84.1 7 15.9 26.62 <0.001
NO 37 37.4 62 62.6

CPE: continuous professional education.

Table 3 Table 5
Comparison of TDMI between Control and Intervention Group. Score of TDMI and PSBQs between RNs and MOAs at Baseline, Post and Follow-
up.
Post-test Comparison Follow-up Comparison
Between Between Variable Designation
group group
RNs MOAs
n Mean SE P-value Mean SE P-value
Mean ± SD Mean ± SD P-value
Control 74 181.13 1.76 <0.001 178.07 2.33 <0.001
Intervention 69 207.79 1.85 197.93 2.44 Baseline TDMI 179.57 ± 11.72 179.53 ± 18.58 0.99
Post-test TDMI 198.58 ± 14.81 191.60 ± 18.15 0.02
Significance level p < 0.05; SE: standard error. Follow-up TDMI 185.65 ± 17.97 188.70 ± 19.46 0.37
Baseline PSBQ 10.71 ± 1.60 10.17 ± 1.85 0.08
Post-test PSBQ 12.55 ± 2.71 11.50 ± 2.50 0.02
Kaakinen, Kyngäs, Tarkiainen, and Kääriäinen [19] reported a statisti-
Follow-up PSBQ 12.22 ± 2.56 11.24 ± 2.65 0.03
cally significant difference in the skills of triaging between the baseline
and post-test measurements among nurses after exposure to triage RNs Registered nurses; MOAs Medical officer assistants.
training. This was also in line with the study conducted by Merchant
et al. [20], which found that an intervention improved accuracy as well 6. Limitations
as the skills of triage decisions among nurses. In their study, Aghaba-
baeian et al. [21] found that the ability of emergency staff in making The information of PSBQs may restrict the ability of RNs and MOAs
accurate triage decisions using patient scenarios increased after ex- to fully assess the real situation of the patient’s condition, which may
posure to educational sessions over a period of time. The findings de- affect their ability to make accurate triage decisions. However, the
monstrated that RNs scored higher for both skill and accuracy of triage precise assessment of the patient’s condition and main complaints at
decisions compared to the MOAs. However, at the follow-up, although triage were provided in the PSBQs.
the RNs scored higher for their accurateness of triage decisions, they
had a lower score for the skill of triage decision-making compared to
the MOAs. It was not possible to compare the results of the current 7. Conclusion
study with a previous study, since no study was found that compared
the skill and accuracy of triage decision-making between RNs and The triage training that was implemented increased the proficiency
MOAs. The current results possibly indicate their capability and interest of the skills and accuracy of triage decision-making among the RNs and
to learn and unlearn, and, thus apply what has been learnt during the MOAs, therefore it is recommended that it be implemented in the
training, thereby providing greater ability to comply and apply, and continuous nursing education/medical education or added as an extra
more chances for improvement. element to the classroom teaching of nursing students in their critical
nursing course, instead of depending solely on the usual Advanced
Trauma Life Support and Basic Life Support courses. In addition new

Table 4
Comparison of PSBQs between Control and Intervention Group.
Pre-test Post-test Follow-up

n Mean SD P-value n Mean SD P-value n Mean SD P-value

Control 74 10.31 0.22 0.75 74 9.64 0.17 <0.001 74 9.48 0.18 <0.001
Intervention 69 10.41 0.23 69 14.25 0.18 69 13.83 0.19

Significance level p < 0.05; SD: standard deviation.

4
S.A. Ghazali, et al. International Emergency Nursing 51 (2020) 100889

member of staff who are posted in the EDs should be provided with an doi.org/10.1016/j.ienj.2020.100889.
adequate orientation prior to performing their roles, depending on in-
dividual capabilities and experience. It is important to expose them to References
the roles undertaken at triage and the triage process itself for the pur-
pose of gaining clinical knowledge, which can then be integrated with [1] Elmqvist C, Fridlund B, Ekebergh M. Trapped between doing and being: first
existing factual knowledge for better and more accurate triaging. providerś experience of “front line” work. International Emergency Nursing
2012;20(3):113–9.
[2] Emergency Medicine and Trauma Services Policy (2012). Medical Development
CRediT authorship contribution statement Division: Ministry of Health Malaysia; 2012.
[3] Dalwai MK, Twomey M, Maikere J, Said S, Wakee M, Jemmy J-P, et al. Reliability
and accuracy of the South African Triage Scale when used by nurses in the emer-
Siti Aishah Ghazali: Conceptualization, Methodology, Data cura- gency department of Timergara Hospital, Pakistan. SAMJ: South African Med J
tion, Writing - original draft, Visualization, Investigation, Supervision, 2014;104(5):372–5.
Validation, Writing - review & editing. Khatijah Lim Abdullah: [4] Brown AM, Clarke DE. Reducing uncertainty in triaging mental health presenta-
tions: examining triage decision-making. Int Emerg Nurs 2014;22(1):47–51.
Conceptualization, Methodology, Validation, Writing - review & https://doi.org/10.1016/j.ienj.2013.01.005.
editing. Foong Ming Moy: Conceptualization, Methodology, [5] Horne S, Vassallo J, Read J, Ball S. UK triage–an improved tool for an evolving
Validation, Writing - review & editing. Rashidi Ahmad: threat. Injury 2013;44(1):23–8.
[6] La Vonne AD, Zun LS, Burke T. Comparison of Canadian triage acuity scale to
Conceptualization, Methodology, Validation, Writing - review &
Australian Emergency Mental Health Scale triage system for psychiatric patients. Int
editing. Emni Omar Daw Hussin: Writing - review & editing. Emergency Nursing 2015;23(2):138–43.
[7] Egberink RE, Otten H-J, IJzerman MJ, van Vugt AB, Doggen CJ. Trauma team ac-
Declaration of Competing Interest tivation varies across Dutch emergency departments: a national survey.
Scandinavian J Trauma Resuscitation Emergency Med 2015;23(1):100.
[8] Rahmani F, Sepehri Majd P, Ebrahimi Bakhtavar H, Rahmani F. Evaluating the
The authors declare that they have no known competing financial accuracy of emergency nurses in correct triage using emergency severity index
triage in Sina hospital of Tabriz: a cross-sectional analysis. J Emergency Practice
interests or personal relationships that could have appeared to influ- Trauma 2018;4(1):9–13.
ence the work reported in this paper. [9] Kadam P, Bhalerao S. Sample size calculation. Int J Ayurveda Res 2010;1(1):55.
[10] Cone KJ. The development and testing of an instrument to measure decision making
in emergency department triage nurses. Unpublished Doctoral Dissertation. Saint
Acknowledgements Louis University, Missouri-2000; 2000.
[11] Cone Kelly Jo, Murray Ruth. Characteristics, insights, decision making, and pre-
The authors thanks to Postgraduate Research Fund (PPP) PG099- paration of ED triage nurses. J Emergency Nursing 2002;28(5):401–6. https://doi.
org/10.1067/men.2002.127513.
2013A, University of Malaya, Malaysia for the financial support; and all
[12] Smith A, Cone KJ. Triage decision-making skills: a necessity for all nurses. J Nurses
healthcare provider who participated in this study. Professional Devel 2010;26(1):E14–9.
[13] Chen S-S, Chen J-C, Ng C-J, Chen P-L, Lee P-H, Chang W-Y. Factors that influence
the accuracy of triage nurses' judgement in emergency departments. Emergency
Conflict of interest
Med J 2010;27(6):451–5.
[14] Göransson KE, Ehrenberg A, Marklund B, Ehnfors M. Emergency department triage:
Our study protocol for the research project has been approved by is there a link between nurses’ personal characteristics and accuracy in triage de-
the Research Ethics Committee, Ministry of Health, Malaysia. Research cisions? Accid Emergency Nurs 2006;14(2):83–8.
[15] Hassani P, Abdi A, Jalali R, Salari N. Use of intuition by critical care nurses: a
ID NMRR-13-1477-16716, Ethics Committee (Human) Universiti Sains phenomenological study. Adv Med Education Practice 2016;7:65.
Malaysia, Health Campus; JEPeM USM code: USM/JEPeM/[282.3(7) [16] Wolf LA, Perhats C, Delao AM, Moon MD, Clark PR, Zavotsky KE. “It’sa burden you
and Universiti Malaya Medical Centre; Ethic Committee Reference carry”: describing moral distress in emergency nursing. J Emergency Nursing
2016;42(1):37–46.
Number/IRB: 1031.1). All are conform to the provisions of the [17] Bucknall TK, Forbes H, Phillips NM, Hewitt NA, Cooper S, Bogossian F. An analysis
Declaration of Helsinki in 1995. We declare that the work submitted are of nursing students’ decision-making in teams during simulations of acute patient
entirely our own is not under consideration in any other journal. All deterioration. J Adv Nurs 2016;72(10):2482–94.
[18] Aloyce R, Leshabari S, Brysiewicz P. Assessment of knowledge and skills of triage
authors have contributed towards the paper, and have read and ap- amongst nurses working in the emergency centres in Dar es Salaam, Tanzania.
proved the final manuscript. We have no conflicts of interest to declare. African J Emergency Med 2014;4(1):14–8.
[19] Kaakinen P, Kyngäs H, Tarkiainen K, Kääriäinen M. The effects of intervention on
quality of telephone triage at an emergency unit in Finland: nurses' perspective. Int
Funding statement Emergency Nursing 2016;26:26–31.
[20] Merchant A, Outhay M, Gonzaléz-Calvo L, Moon TD, Sidat M, Taibo CLA, et al.
This study project was supported by University of Malaya Post Training laypersons and hospital personnel in basic resuscitation techniques: an
approach to impact the global trauma burden in Mozambique. World J Surg
Graduate Research Grant (PG099-2013A), Kuala Lumpur Malaysia.
2015;39(6):1433–7.
[21] Aghababaeian H, Sedaghat S, Tahery N, Moghaddam AS, Maniei M, Bahrami N,
Appendix A. Supplementary data et al. A comparative study of the effect of triage training by role-playing and
educational video on the knowledge and performance of emergency medical service
staffs in Iran. Prehospital Disaster Med 2013;28(6):605–9.
Supplementary data to this article can be found online at https://