Accident and Emergency Nursing (2005) 13, 206–213

Accident and

www.elsevierhealth.com/journals/aaen

EmergencyNursing

An exploration of accident and emergency nurseexperiences of triage decision making in Hong Kong

Josephine Y.M. Chung RN, MN, BSN(Hon)

No. 11, Chuen On Road, Alice Ho Miu Ling Nethersole Hospital, NT, Hong Kong

Received 4 February 2005; received in revised form 1 July 2005; accepted 2 August 2005Available online

Summary This study used a descriptive qualitative design to explore emergencynurse experiences of decision making about triage in Hong Kong. Seven experiencednurses who were working in three different accident and emergency departmentsparticipated in the study. Unstructured interviews were used to provide the nurseswith opportunities to describe their experiences. The findings fall into three maincategories, including the experience of triage decision making, the use of informa-tion in the triage decision-making process, and the factors that influence triagedecision making. Although the experience of triage was generally positive, thenurses felt frustrated and uncertain in some circumstances. In addition, triage deci-sion making was influenced by a series of factors that occur in daily practice. Thefindings of this study have implications for the development of formal triage trainingand triage decision-making protocols in accident and emergency nursing. They alsoprovide positive reinforcement and support to triage nurses that will enhance theirability to make decisions about triage. Avenues for further research in the area arerecommended.

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KEYWORDSTriage;Triage nurse;Triage decisionmaking;Experience

0d

Introduction

The purpose of triage is to prioritize patient ur-gency among those who attend emergency depart-ments (EDs) (Handysides, 1996). Decision making isan important component of triage practice (Lepro-hon and Patel, 1995; Cioffi, 1998; Gerdtz andBucknall, 1999; Marsden, 1999; Lyneham, 1998).Decision making in different clinical settings sharessome fundamental aspects. However, unlike other

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clinical settings, there are some key differencesin triage decision making. Gerdtz and Bucknall(1999) summarized how the nature of triage re-quires the nurse to act on decisions as an indepen-dent practitioner. Firstly, the triage nurse isgeographically isolated from the rest of the EDand is required to make decisions without inputfrom colleagues. Secondly, the triage nurse hasthe sole responsibility of providing care for all pa-tients in the waiting area until resources are avail-able within the accident and emergency (A&E)department. Thirdly, the triage nurse may refer

ved.

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 207

non-urgent patients to the appropriate health careproviders, and that will expedite the care of semi-and non-urgent patients in the waiting area (Emer-gency Nurse Association, 1992). Finally, the triagenurse has a unique overview of the workload ofthe department, and plays a central role in manag-ing the flow of patients through the department(Nuttall, 1986; Rice and Abel, 1992). However,McCaughan (2002) argues that in practice, nursesusually make decisions collaboratively and rarelymake decisions alone. They seek information inthe form of advice from their colleagues and otherprofessionals on how to act when faced with anuncertain situation. The nature of triage decisionmaking does not always allow this to take place.

When Lipshitz and Strauss (1997) analyzed 102self-reports of decision making in uncertain situa-tions, they found that the decision makers distin-guished three types of uncertainty: inadequateunderstanding, incomplete information, and undif-ferentiated alternatives. The challenge of triagedecision making is that nurses need to make deci-sions rapidly and with limited patient information.Due to time constraints or communication difficul-ties, these nurses may often make decisions withincomplete information and a limited understand-ing of the patients’ problem. Crouch and Dale(1994) and Geraci and Geraci (1994) found thatinterruptions take place during the triage process.Thus, the influence of incomplete information maybe further compounded by the nature of the triageprocess itself.

Triage decisions are often associated with cer-tain levels of risk to the patient, nurse and theorganization, and might lead to legal conse-quences (Gerdtz and Bucknall, 1999). Jenis andMann (1977) identified two types of clinical deci-sions: ‘‘hot’’ decisions, which are unusually com-plex and result in unpleasant emotional arousal,and ‘‘cold’’ decisions which are made when therisks are minimal (p. 45). ‘‘Hot’’ decisions arethose decisions made by nurses, and may inducea certain a degree of stress. ‘‘Cold’’ decisionsare those that are made following rules, algo-rithms, or protocols (Bucknall and Thomas,1997). In Hong Kong, triage guidelines provideonly a reference for triage decision making; theactual triage decisions rely heavily on the nurse’sown judgment. Decision making under these cir-cumstances often creates some degree of stressand personal risk to the triage nurse and the pa-tient. Increased stress and personal risk withinthe clinical environment may lead to a decreasein the result of the efficiency and effectivenessof the decision-making process. Bucknall and Tho-mas (1997) also found that perceived personal and

professional risks are factors that may influencedecision making by critical care nurses.

Different triage categorization scales were de-signed in some countries in the 1990s. These in-cluded the Australian National Triage Scale (NTS),the Manchester Triage Guidelines and some modi-fied national triage guidelines such as the Emer-gency Severity Index that was recently developedin the US (Gilboy et al., 1999). Triage scales andguidelines aim to provide a uniform method to en-able an informed triage decision to be made inrelation to a patient’s treatment priority. Hence,the focus of triage research in the 1990s was to testthe reliability and validity of these triage scales(Brillman et al., 1996; George et al., 1996; Bondet al., 1997; Dent et al., 1999). Such studies fo-cused mainly on measuring the predictability andreliability of triage categorizing, determining suchthings as admission, discharge, death rate, andlength of waiting time. They pointed out that inac-curate category allocations can lead to the inade-quate utilization of health resources and adversepatient outcomes (Gerdtz and Bucknall, 1999).Using this approach as the only way to understandtriage practice will limit the scope of knowledgeof this contemporary role. Moreover, if researchonly focuses on the outcome measures, the factorsthat influence the process of triage will be madeirrelevant (Fry and Burr, 2002). Although someresearchers have demonstrated a strong reliabilityand validity of some triage guidelines and scales(Beveridge et al., 1999), triage code allocationsare still inconsistent (Considine et al., 2000). Con-sistency in applying triage scale means that ‘‘a pa-tient with a specific problem should be allocated tothe same triage category, irrespective of the insti-tution to which they have presented themselves orthe personnel performing the role of triage’’(Considine et al., 2000, p. 202). Various studieshave reported inconsistency in triage category allo-cation by nurses (Wuerz et al., 1998; Fernandeset al., 1999), experienced accident and emergencydoctors (Goodacre et al., 1999) and betweennurses and doctors (Song-Seng et al., 2002; Ber-geron et al., 2002). In practice, triage nurses sel-dom rely on triage guidelines alone to makedecisions (Fry and Burr, 2001; Gerdtz and Bucknall,2000). This is particularly true of experiencednurses, and may contribute to inconsistent applica-tion of the guidelines. (Cone and Murray, 2002).

Several studies that have assessed the triageprocess have shown that the main concerns areabout the objective data taken by triage nurses,such as vital signs (including blood pressure,pulse and temperature) or examinations such asthose for the blood glucose level, urine tests,

208 J.Y.M. Chung

neurological observations, or rapid electrocardio-grams (Standen and Dilley, 1997; Graff et al.,2000). Studies have reported that physiologicaldata are considered less by triage nurses when mak-ing acuity decisions (Gerdtz and Bucknall, 2001;Cooper et al., 2002; Lyneham, 1998). Lyneham(1998) used a modified grounded theory frameworkto validate the hypothetico-deductive decision-making model among emergency nurses. She foundthat nurses utilized verbal, non-verbal, and othersources of information in clinical inquiry, whereasobjective measurements were used relatively latein the process. Salk et al. (1998) conducted atwo-phase, prospective, observational study thatemployed a randomized, crossover design in anemergency department in a university teaching hos-pital. The study compared triage category alloca-tions that were derived from face-to-face andtelephone triage, and systematically examined theeffect of visual cues, vital signs, and complaint-based protocols on the triage process. Knowledgeof vital signs and use of protocols did not improvethe agreement of triage designations betweengroups, which suggested that visual cues may playan important role in the triage assessment process.The information used for triage decision making notonly depends on objective data, but also dependson subjective cues that are perceived by nurses.Handysides (1996) has pointed out that sometimespatients have atypical symptoms and vague com-plaints, and the experienced triage nurse often dis-covers subtle signs of a serious health problem,even though all objective data is normal. This sub-jective assessment strategy is described as ‘‘gutfeeling’’ or ‘‘intuition’’ in the literature (Offredy,1998; Marsden, 1999; Grossman, 1999). It is hopedthat an in-depth exploration of nurses’ triage deci-sion making experiences will provide new insightsinto these issues.

Objective

The objectives of this study are to gain an under-standing of the triage decision making experiencesof emergency nurses and of the contextual influ-ences on triage decision making in accident andemergency departments.

Method

A qualitative research method was chosen and adescriptive design was used in this study. Fry andBurr (2002) also agree that in-depth interviews

can provide a new way of viewing triage nurses’work within a broader context.

Sampling

Purposive sampling, a commonly applied method,was used in this study. Purposefully sampling dic-tates that the researcher focuses on the theoreti-cal needs of the study and the informant’sknowledge of the research topic to invite the bestsuitable people to participant in the study (Morse,1991). The participants had to be emergencynurses who were currently involved in the triageprocess with at least 1 year of experience in triage.

Morse and Field (1998) suggest that the samplesize is determined when no new information canbe obtained from further interviews. In this study,no new information emerged after interviewing se-ven emergency nurses.

Gaining access and procedures

The Survey and Behavioral Research Ethics Com-mittee of the Chinese University of Hong Kongand the Joint Chinese University-North TerritoriesEast Cluster Clinical Research Ethical Committee(Joint CUHK-NTEC Cluster CREC) approved the re-search. Information sheets, including an explana-tion of the purpose and procedure of the study,were sent to emergency nurses who met the studycriteria. All participants were interviewed over a 2-month period. Interviews were conducted in aquiet and private room, and each interview was re-corded on tape and transcribed for analysis. Theduration of each interview was approximately40 min.

Instrument and data collection

In qualitative research, the interviewer is the re-search instrument. Unstructured open interviewswere conducted to collect the data, because littlewas known about the experiences of emergencynurses in triage decision making (Morse and Field,1998). To help the participants to tell their stories,they were first asked to describe their experiencesin triage decision making. Participants who wereuncertain about where to begin were encouragedto start wherever they wished (Morse and Field,1998) or at a point that impressed them about tri-age decision making, as suggested by Streubert andCarpenter (1995). Moreover, participants were ad-vised to describe their experiences rather thaninterpret them. When probing was required, it con-sisted of ‘‘tell me more about that’’ or ‘‘what did

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 209

that mean to you?’’. Immediately after each inter-view field-notes were recorded to ensure that sig-nificant observations, experiences, and thoughtswere not missed.

Data analysis

The interviews were conducted in Cantonese andthe recorded interviews were transcribed verbatimfor analysis. Data analysis was based on the codingsystem described by Miles and Huberman (1994).After going through the data analysis steps, all cat-egories and supporting narrative texts were trans-lated into English. The final transcript andcategories were returned to the participants forcomments, feedback and validation (Leininger,1994). There was no information feedback fromthe participants and they all agreed on the themesthat were generated from the transcripts.

Findings

Demographic characteristic of theparticipants

The seven participants worked in three differentemergency departments. All of the participateswere female. The average years of experiencein A&E was 9 years, and ranged from 5 to 11years. Three of the participants had chosen towork in the A&E department and the remainingfour were assigned to the department by the hos-pital. The participants had all received sometraining in A&E nursing, but none of them had re-ceived any formal training on triage decisionmaking. Six of them had finished a 1-year emer-gency-nursing course, which covered minimaltraining in triage decision making. Six of the par-ticipants had Bachelor of Nursing degrees, andone had a Masters degree in Nursing.

Nurse experiences of triage decision making

Autonomy and satisfactionAll of the participants reported that they held posi-tive attitudes toward the role of triage decisionmaking. They reported that this role gave themmuch autonomy and satisfaction in triage decisionmaking.

Feelings of frustrationThe participants all expressed that they hadencountered challenges in their triage decisionmaking at different stages. Challenges from col-

leagues and medical teams made them feelfrustrated.

When faced with such challenges, one partici-pant lost confidence in her decision-making skillswhen she was a junior. The majority of the partici-pants changed their decisions when they were lessexperienced. However, being more experienced,they now felt more confident with their decisions.Two nurses reflected that they had tried to asserttheir decisions with their senior colleagues andmedical staff.

Feeling uncertaintyThe participants understood that it was theirresponsibility to make an accurate decision whenprioritizing patient urgency. However, they weresometimes uncertain in triage decision making.They felt uncertain when a patient’s conditionchanged during a long waiting period. Uncertaintiessuch as these made them feel that triage decisionmaking was stressful and risky. Five participantsshared the same feelings when handling patientswho presented with ‘‘borderline’’ symptoms(symptoms that were in between two different cat-egories), particularly during long waiting periods.Three participants said they would upgrade the pa-tient’s category depending on the waiting time andconditions so that they could prevent the deterio-ration of the condition.

As one participant commented:

‘‘. . . if the patient’s waiting time could be long, say3–4 h, I would upgrade this category 4 case to cat-egory 3. Because. . . you don’t know what wouldhappen if you let them wait for 3–4 h. That wouldrisk the patient’s health. . . and so I would upgradethe category and let them to see the doctor ear-lier.’’ (Nurse 1)

Two participants mentioned that they would re-assess borderline cases during peak periods (longpatient waiting time) and would adjust the triagecategory accordingly. Some participants reportedthat they would upgrade a borderline patient’s cat-egory during peak periods; two participants re-ported that they were sometimes hesitant aboutdoing so because they were worried that their deci-sion might be a burden on other colleagues.

The information used in triage decisionmaking

Use of experiencePrevious clinical experience was the main compo-nent in the triage decision-making process accord-ing to most of the participants.

210 J.Y.M. Chung

Two participants specifically identified that re-cent, impressive experiences had made them morealert during the decision-making process. More-over, these experiences had assisted them inrevealing patient critical conditions, even if thepatient presented with non-specific symptoms.

Information from pre-hospital personnel andpatientsOne participant mentioned that information fromother professionals such as ambulance staff orpolice could affect triage decision making. Allof the participants believed that information gi-ven by patients was significant to triage decisionmaking, but four participants reported that somepatients might not give accurate information inthe triage assessment, which in turn would affecttheir ability to allocate an appropriate triagecategory.

IntuitionFour participants reflected that they would usesubjective data such as intuition in some situationsto reach triage decisions. These approaches wereinternalized and used automatically in the deci-sion-making process.

As one participant commented:

‘‘I find that the triage decision making sometimesdepends on my sixth senses, . . .ha, ha. . . sometimesthe data does not reflect the problem of a patient.However, when you feel something wrong aboutthe patient, you give them a higher priority.’’(Nurse 2)

Triage guidelines and pre-established triagecriteriaAlthough triage guidelines provided assistance intheir decision making, all of the participants re-ported that the triage guidelines were simply a ref-erence for triage decision making. They followedthe guidelines loosely, as not all of the situationsrelating to patient conditions fitted the guidelinecategories. Two participants claimed that theyhad followed the triage guidelines when they wereless experienced. Three said that they would referto the triage guidelines when they found somethingambiguous.

As one participant said:

‘‘The guidelines provide limited and fixed informa-tion that might not be adapted to the real situationwhen you handle the patient. Sometimes, you can-not find a suitable category to match a patient’scase according to the guidelines.’’ (Nurse 1)

Four participants reported that some pre-estab-lished triage criteria should be followed to maketriage decisions even though they felt that the tri-age category was not always appropriate for thepatient.

Factors that influence the triage decision-making process

Interruptions, time constraints and lack of trainingwere the factors identified by participants as thoseinfluencing the triage decision-making process.

InterruptionsAll of the participants reported that interruptionsusually happened when they were making triagedecisions. For example, other patients’ enquiries,a sudden case occurring in the waiting hall, orthe arrival of new patients. Four participants saidthat interruptions affected their decision-makingprocess and sometimes this led to them missinginformation from patients.

As one participant described:

‘‘If many people are asking you questions or otherpatients are suddenly getting into worse conditions,you need to suspend your triage decision-makingprocess for a while (to manage the problem). . .when you get back to the case, you might forgetsome information that should be asked yourpatient.’’ (Nurse 6)

Time constraintsAlthough there was no definite time limit set toreach a triage decision, two participants felt thatit was difficult to make an accurate triage decisionin a short period. They said that time constraintswere an influencing factor in their decision-makingprocess.

Lack of formal trainingEven though all of the participants expressed thattraining was an essential factor to facilitate the tri-age decision making, only two participants high-lighted the importance of questioning skills tohelp them collect more accurate information dur-ing the assessment stage of triage. Four partici-pants mentioned that updated medical knowledgecould help them effectively assess the signs andsymptoms of patients.

Three participants mentioned that receivingsome constructive feedback and advice from col-leagues had made a strong impression on themand could help them to effectively handle similarcases in the future.

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 211

Discussion

The emergency nurses had positive attitudes to-ward the role of triage. However, they reported dif-ficulties in the process of triage decision making.The triage nurses experienced uncertainty and feltthey were at risk when making decisions about pa-tients with borderline symptoms and when therewere long waiting periods. These issues have notbeen reported in previous studies. One possibleexplanation may be that most previous studies havebeen quantitative and have focused on the accuracyand consistency of triage practice. In this study,nurses experienced uncertainty in allocating a cat-egory to patients with borderline symptoms whichmay have been because they could not obtain moreprecise information from patients. In addition, thenurses perceived that the longer a patient waitedto see the doctor, the higher the risk of deteriora-tion in their condition. The nurses feared that anincorrect triage category allocation may lead to adelay in treatment and at worst, the death of a pa-tient, particularly when waiting a long time. Suchoutcomes may have legal consequences.

In managing uncertainty, particularly with bor-derline patients the majority of nurses reportedthat they upgraded the triage category during longwaiting periods. They perceived that adopting thisstrategy was safe for both patients and nurses. Lessexperienced triage nurses are more likely to make‘‘over-triage’’ decisions (Considine et al., 2000).Interestingly, the decision to over-triage was alsorevealed by experienced emergency nurses in thisstudy. However, some nurses only consideredupgrading the triage category when dealing withpatients with borderline symptoms during longwaiting periods. This decision strategy suggeststhat nurses felt uncomfortable and uncertain underthese circumstances. However, over-triage maynot be considered as good practice for theemergency service and it may not achieve the ulti-mate goal of triage. In addition, it will invariablylengthen the waiting time in the same categorygroup, and the borderline cases may not really war-rant the upgrade. The decision to over-triage mayinduce inconsistency in triage category allocations,because the perception of borderline symptomsmay vary among individual nurses. To reduceuncertainty and the feeling of risk in triage prac-tice, a clear legal liability of the triage role shouldbe explained to the nurses to make sure that theirperformance is not influenced by unnecessary anx-iety. Moreover, triage protocols could be used as asupporting tool for triage decision making in pa-tients with borderline symptoms.

Most of the nurses in this study described theexperience of being challenged during triage deci-sion making. Another local study produced similarfindings (Lau, 2001), whereby challenges from co-workers were reported as a factor that influencedtriage decision making. This issue was also reportedby Cone and Murray (2002), who found that triagenurses thought that their peers did not always re-spect or support their decisions. A possible reasonis that nurses have no uniform triage educationand different training backgrounds between physi-cians and nurses may contribute to a lower levelof agreement in triage categorization. Hamerset al. (1994) point out that judgment will differin different domains between nursing and medicineknowledge. Standen and Dilley (1997) asserted thatuniform triage training can ensure that all triagenurses work from the same knowledge base anduse the same principles to assess and categorizepatients.

The majority of the nurses admitted that pastexperiences played an important factor in their tri-age decision making, which is also described in pre-vious literature (Cone and Murray, 2002; Cioffi,1998). The nurses reported that experience of sim-ilar cases or recent and impressive cases helped tomake them more alert in the decision-making pro-cess. These experiences helped them to revealcritical conditions. Moreover, most nurses reportedthat they used intuition in the triage decision-mak-ing process. This subjective decision-making ap-proach is referred to as the ‘‘representativeheuristic’’ (Cioffi, 1997, p. 189). A number of stud-ies have reported that triage nurses, usually thosewho are more experienced, use the representativeheuristic in triage decision making (Lyneham, 1998;Marsden, 1999; Cioffi, 1998; Gerdtz and Bucknall,2001). Intuition may be used as a result of individ-ual exposure to information that pertains to partic-ular cases such as nurses’ past clinical experiences,and exposure to case reports in professional jour-nals (Schwartz and Griffin, 1986; Benner and Tan-ner, 1987). Cioffi (1998) argued that the use ofrelevant past experiences by nurses in triage deci-sion making could be an advantage in reaching adecision. However, intuition might bias the real sit-uation in triage decision. Friedlander and Stockman(1983) point out that people tend to use the closestinformation to hand when making decisions, butthe problem with this reasoning approach is thatwhat is available may not be suitable in each indi-vidual case, and can result in variation in decisions(Thompson and Dowding, 2002). Moreover, ifnurses use this ‘‘closed-minded assumption’’ (p.87) they fail to show that their intuitions are sound

212 J.Y.M. Chung

which can also be a substitute for lack of knowl-edge (Bandman and Bandman, 1988). Although,none of the participants expressed that they onlyused objective or subjective data to make triagedecisions, it is important that nurses use subjectiveinformation cautiously to avoid bias in the triageassessment process.

The nurses reported that interruptions were afrequent problem that influenced triage decisionmaking. This finding is shared with other studies inthe literature (Crouch and Dale, 1994; Geraci andGeraci, 1994; Gerdtz and Bucknall, 2001), in whichthe results indicated that triage decision making islikely to be influenced by nursing activities andenvironmental factors. Gerdtz and Bucknall (2001)found that interruptions could significantly increasethe duration of the triage process, which is similarto the findings of an earlier study (Geraci andGeraci, 1994) and will further delay emergencypatients from receiving initial triage assessment.

Triangulation of data collection is suggestedwhen repeating this study (Sandelowski, 1986).For example, the researcher should collect datathrough interviews and on-site observation, so thedata from both sources can be compared to forma complete picture of the issue.

Conclusion

Triage nurses face diverse patient groups everyday. They should accurately prioritize patients toreceive treatment at the appropriate time. Thisstudy has revealed that triage decision making isinfluenced by a series of contextual factors that oc-cur in daily practice. These factors should be takeninto consideration to improve and enhance theaccuracy of triage decision making.

References

Bandman, E.L., Bandman, B., 1988. Critical Thinking in Nursing.Appleton & Lange, London.

Benner, P., Tanner, C., 1987. Clinical judgement: how expertnurses use intuition? American Journal of Nursing 87 (1) 23–31.

Bergeron, S., Gouin, S., Bailey, B., Patel, H., 2002. Comparisonof triage assessments among pediatric registered nurses andpediatric emergency physicians. Academic Emergency Med-icine 9 (12), 1397–1401.

Beveridge, R., Ducharme, J., Janes, L., Beaulieu, S., Walter, S.,1999. Reliability of the Canadian emergency departmenttriage and acuity scale: interrater agreement. Annual ofEmergency Medicine 34 (2), 155–159.

Bond, R.J., Kortbeek, J.B., Preshaw, R.M., 1997. Field traumatriage: combining mechanism of injury with the pre-hospitalindex for an improved trauma triage tool. Journal of Trauma:Injury, Infection and Critical Care 43 (2), 283–287.

Brillman, J.C., Dozema, D., Tandberg, D., Skalar, D.P., Davis,K.D., Simma, S., 1996. Triage: limitations in predicting theneed for emergency care and hospital admission. Annals ofEmergency Medicine 27 (4), 493–500.

Bucknall, T., Thomas, S., 1997. Nurses’ reflections on problemsassociated with decision-making in critical care setting.Journal of Advanced Nursing 25 (2), 229–237.

Cioffi, J., 1997. Heuristics: servants to intuition in clinicaldecision making. Journal of Advanced Nursing 26 (1), 203–208.

Cioffi, J., 1998. Decision making by emergency nurses in triageassessment. Accident and Emergency Nursing 6 (4), 184–191.

Cone, K.J., Murray, R., 2002. Characteristics, insights, decision-making, and preparation of ED triage nurses. Journal ofEmergency Nursing 28 (5), 401–406.

Considine, J., Ung, L., Thomas, S., 2000. Triage nurses’ decisionusing the national triage scale for Australian emergencydepartments. Accident and Emergency Nursing 8 (4), 201–209.

Cooper, R.J., Schriger, D.L., Flaherty, H.L., Lin, E.J., Hubbell,K.A., 2002. Effect of vital signs on triage decisions. Annals ofEmergency Medicine 39 (3), 223–232.

Crouch, R., Dale, J., 1994. Identifying feelings engenderedduring triage assessment in the accident and emergencydepartment: the use of visual analogue scales. Journal ofClinical Nursing 3 (5), 289–297.

Dent, A., Rofe, G., Sansom, G., 1999. Which triage categorypatients die in hospital after being admitted through emer-gency departments. A study in one teaching hospital.Emergency Medicine 11 (2), 68–71.

Emergency Nurse Association, 1992. Triage Meeting the Chal-lenge. Emergency Nurse Association USA Publication, ParkRidge.

Fernandes, C., Wuerz, R., Clark, S., Djurdjev, O., 1999. Howreliable is emergency department triage? Annals of Emer-gency Medicine 34 (2), 141–147.

Friedlander, M., Stockman, S., 1983. Anchoring and publicityeffects in clinical judgement. Journal of Clinical Psychology39 (4), 637–643.

Fry, M., Burr, G., 2001. Current triage practice and influencesaffecting clinical decision making in emergency departmentsin NSW, Australia. Accident and Emergency Nursing 9 (4),227–234.

Fry, M., Burr, G., 2002. Review of the triage literature: past,present, future? Australian Emergency Nursing Journal 5 (2),33–38.

George, J.E., Quattrone, M.S., Goldstone, M., 1996. Law and theemergency nurse. Triage protocols. Journal of EmergencyNursing 21 (1), 65–66.

Geraci, E.B., Geraci, T.A., 1994. An observational study of theemergency triage nursing role in a managed care facility.Journal of Emergency Nursing 20 (3), 189–194.

Gerdtz, M.F., Bucknall, T.K., 1999. Why we do the things we do:applying clinical decision-making framework to triage prac-tice. Accident and Emergency Nursing 7 (1), 50–57.

Gerdtz, M.F., Bucknall, T.K., 2000. Australian triage nurses’decision-making and scope of practice. Australian Journal ofAdvanced Nursing 18 (1), 24–33.

Gerdtz, M.F., Bucknall, T.K., 2001. Triage nurses’ clinicaldecision making. An observational study of urgency assess-ment. Journal of Advanced Nursing 35 (4), 550–561.

Gilboy, N., Travers, D., Wuerz, R., 1999. Re-evaluating triage inthe new millennium: a comprehensive look at the need forstandardization and quality. Journal of Emergency Nursing 25(6), 468–473.

Goodacre, S.W., Gillett, M., Harris, R.D., Houlihan, K.P.G.,1999. Consistency of retrospective triage decisions as a

Exploration of accident and emergency nurse experiences of triage decision making in Hong Kong 213

standardized instrument for audit. Journal of Accident andEmergency Medicine 16 (5), 322–324.

Graff, L., Palmer, A.C., LaMonica, P., Wolf, S., 2000. Triage ofpatient for a rapid (5-minute) electrocardiogram: a rulebased on presenting chief complaints. Annals of EmergencyMedicine 36 (6), 554–560.

Grossman, V.G.A., 1999. Quick Reference to Triage. Lippincott,Philadelphia.

Hamers, J.P.H., Huijer Abu Saad, H., Halfens, R.J.G., 1994.Diagnostic process and decision making in nursing: a litera-ture review. Journal of Professional Nursing 10 (3), 154–163.

Handysides, G., 1996. Triage in Emergency Practice. Mosby, St.Louis.

Jenis, I., Mann, I., 1977. Decision Making: A PsychologicalAnalysis of Conflict, Choice and Commitment. Free Press,New York.

Lau, P.F., 2001. Decision making of triage nurses in determina-tion of patients’ level of urgency in accident and emergencydepartment. Unpublished Master’s Thesis, The Hong KongPolytechnic University.

Leininger, M., 1994. Evaluation criteria and critique of qualita-tive research studies. In: Morse, J.M. (Ed.), Critical Issue inQualitative Research Method. Sage, Thousand Oaks, pp. 95–115.

Leprohon, J., Patel, V.L., 1995. Decision-making strategies fortelephone triage in emergency medical service. MedicalDecision Making 15 (3), 240–253.

Lipshitz, R., Strauss, O., 1997. Coping with uncertainty: anaturalistic decision-making analysis. Organizational Behav-iour and Human Decision Processes 69 (2), 149–163.

Lyneham, J., 1998. The process of decision-making by emer-gency nurses. Australian Journal of Advanced Nursing 16 (2),7–14.

Marsden, J., 1999. Expert nurse decision-making: telephonetriage in an ophthalmic accident and emergency department.NTResearch 4 (1), 44–52.

McCaughan, D., 2002. What decisions do nurses make? In:Thompson, C., Dowding, D. (Eds.), Clinical Decision Makingand Judgement in Nursing. Churchill Livingstone, London, pp.96–108.

Miles, M.B., Huberman, A.M., 1994. Qualitative Data Analysis,second ed. Sage, Thousand Oaks.

Morse, J.M., 1991. Strategies for sampling. In: Morse, J.M. (Ed.),Qualitative Nursing Research: A Contemporary Dialogue.Stage, Newbury Park, pp. 127–145.

Morse, J.M., Field, P.A., 1998. Nursing Research: The Applica-tion of Qualitative Approaches, second ed. Stanley Thornes,Cheltenham.

Nuttall, M., 1986. The chaos controller emergency departmenttriage. Nursing Times 82 (20), 14–20.

Offredy, M., 1998. The application of decision making conceptsby nurse practitioners in general practice. Journal ofAdvanced Nursing 28 (5), 988–1000.

Rice, M., Abel, C., 1992. Triage. In: Budassi-Sheehy, S. (Ed.),Emergency Nursing Principles and Practice, third ed. Mosby,St. Louis.

Salk, E., Schriger, D.L., Hubbell, K.A., Schwartz, B.L., 1998.Effect of visual cues, vital signs, and protocols on triage: aprospective randomized crossover trial. Annals of EmergencyMedicine 32 (6), 655–664.

Sandelowski, M., 1986. The problem of rigor in qualitativeresearch. Advances in Nursing Science 8 (3), 27–37.

Schwartz, S., Griffin, Y., 1986. Medical Thinking: The Psychologyof Medicial Judgement and Decision Making. Springer, NewYork.

Song-Seng, L., Shiumn-Jen, L., Lee, K.T., Tiing-soon, L., Wong-Tsai, C., 2002. Evaluation of nurse–physician inter-observeragreement on triage categorization in the emergencydepartment of a Taiwan medical center. Chang Gung Med-icine Journal 25 (7), 446–451.

Standen, P., Dilley, S.J., 1997. A review of triage nursingpractice and experience in Victorian public hospitals. Emer-gency Medicine 9 (4), 301–305.

Streubert, H.J., Carpenter, D.R., 1995. Qualitative Research inNursing. Lippincott, Philadelphia.

Thompson, C., Dowding, D., 2002. Clinical Decision Making andJudgement in Nursing. Churchill Livingstone, London.

Wuerz, R., Fernandes, C., Alarco, J., 1998. Inconsistency ofemergency department triage. Annals of Emergency Medi-cine 32 (4), 431–443.