Background

The emergency department provides unique health services, as it must accept patients with various medical conditions and prioritize them based on clinical urgency. This measure requires fast and precise actions despite unpredictable patient numbers and resource availability (1). Priority for treatment based on medical urgency is evaluated using a triage system (2). Accurate and timely triage decisions are crucial for efficient emergency medical services (3).

Triage teams face the challenge of assessing patients quickly and accurately with limited information (4). Triage decisions rely on officer expertise, and inappropriate decisions can result in treatment delays or worsen a patient's condition, underscoring the need for triage training, in line with a previous study suggesting that a lack of training can be related to inaccurate triaging (5). Continuous training is essential to improve the decision-making confidence of officers (6). Research conducted in Iran revealed that delivering and discussing triage training material increased triage practice scores among nurses (7).

A triage training program was held to improve service performance in the emergency room (ER) and revitalize the role and function of triage. The training was carried out amid the COVID-19 pandemic, which hampered mobility and required an online/in-person hybrid setting. Hybrid learning, a combined approach that includes both online and face-to-face instructional methods, was widely adopted during the COVID-19 crisis due to its advantages (8). These include flexibility in terms of time and location, allowing participants to learn at their own pace and according to their learning style, convenient lecture recording, and the freedom for trainers to use a variety of effective training methods such as lectures, group discussions, simulations, and problem-based projects, as well as providing feedback mechanisms (8, 9). In research related to health programs, hybrid learning is as effective as, or more effective than, traditional learning in performance assessment and evaluation (10).

Triage and training materials were delivered online, and the practicum occurred in person while complying with applicable social-distancing rules (11). Self-evaluation continued post-training to obtain training responses through Focus Group Discussions (FGDs). FGDs are useful for collecting data by allowing participants to understand each other's thoughts and experiences to improve the quality of triage services in the ER (12). This study is expected to help evaluate the effectiveness of technical triage training and the professionalism of triage officers in carrying out assessments. The ultimate goal is to improve the future quality of ER triage services.

Objectives

This study explored perceptions of the technical evaluation for triage training and the professionalism of officers responsible for conducting assessments.

Methods

This qualitative study was conducted in a tertiary hospital ER in Jakarta, using FGDs to understand the perceptions of ER medical personnel regarding the hospital triage training that was carried out in November 2021.

Seventy-seven participants, including doctors, nurses, and midwives, took part in triage training at the hospital. The participants were recruited using purposive sampling based on the inclusion and exclusion criteria (Table 1).

Due to the pandemic, a hybrid approach was used for triage training, combining in-person and remote work (10). The training program was accessible online for eight days through the learning management system. It included videos covering triage topics such as the step-by-step process, trauma biomechanics, triage officer roles during resuscitation and transportation, triage therapeutic communication, International Patient Safety Goals application, and infection control.

Table 1. Inclusion and Exclusion Criteria

In-person practicum assignments, including simulations, role-plays, case discussions, and field practice followed the program. Upon completing the training, the participants completed a self-reflection sheet utilizing the six stages of Gibbs' self-reflection cycle: description, feelings, evaluation, analysis, conclusion, and follow-up plan. An expert panel specializing in emergencies reviewed the sheet to select statements for inclusion in FGD exploration. After carefully assessing the participant statements, 21 individuals were selected for the FGD. This group included five doctors, 11 nurses, and five midwives. The general characteristics of the FGD participants are presented in Table 2.

Data were collected in March 2022 by conducting an FGD with three groups (doctors, nurses, and midwives). Before the discussion, the research team, consisting of four emergency specialist doctors, two medical doctors, and two nurses from the emergency department, re-assessed participant self-reflection sheets, prepared questions, and planned the FGD implementation. The discussion process was conducted using a semi-structured interview method, moderated by an emergency specialist doctor, and all participant statements were recorded with their permission and documented by a single note-taker.

During the discussion, participants were asked about their experiences during field practice in triage training, the necessary resources, and their evaluation of both the triage system and training. The discussion for each participant comprised six open-ended questions listed in Table 3. One FGD was conducted per group, lasting 30 minutes to 1 hour (average 44 minutes and 23 seconds). Upon completing the FGD, the session recording was transcribed and carefully reviewed multiple times for a thorough understanding of the interview. Following the interview, the interviewees were also contacted for any clarifications.

Inductive data analysis was conducted using QDA Miner Lite and SPSS Statistics 25. Data analysis and coding were performed and validated by clinicians with more than five years of experience in the emergency field. Additionally, they have been certified as triage-training facilitators. The researchers simultaneously reviewed the FGD transcripts and proceeded with open coding. Each preliminary code was read multiple times and compared to identify and categorize them based on their similarities and differences. Themes were identified, defined, and categorized from the FGD transcripts relating to participant self-reflection on the triage system implementation and training in the hospital ER. To finalize the definition of a theme, the researchers compiled several sub-themes related to the agreed theme and discussed any contentious points to reach a final agreement and consistency.

Results

The FGD involved 21 participants, including five general practitioners, 11 nurses, and five midwives. Qualitative analysis of the FGD transcripts produced six themes: personal readiness for training, triage role, triage errors, officer communication, triage performance, and improvements in the triage training system (Table 4).

Discussion

In this study, we used FGDs to explore the opinions of participants involved in triage training. They provide insights into the skills required for a triage officer to conduct an assessment and evaluate the training they had undergone. When making triage decisions, self-confidence can influence an officer's judgment. According to one study, experienced officers significantly outperformed less experienced ones in triage (14). Another study by Kriengsoontornkij showed that work experience positively correlates with triaging success (15). Sufficient experience in the emergency department can prevent death, disability, and additional healthcare costs.

Self-confidence can be related to the staff's emotional status during patient interaction. Triage nurses require strong psychological capabilities to handle stressful situations. They must remain patient, emotionally stable, and tolerant when treating patients and their families in distress in the ER. Lin et al. found that emergency staff require resilience to effectively use their clinical abilities and act in critical situations (16).

Nurses from the ER and other departments participated in this triage training program. They were eager to establish patient zoning during triage, which could have created an opportunity for team formation among participants who had not previously received triage training.

During the discussion, several officers said they were used to triage assessments and found training and field practice easy. A study by Abbas and Fathoni stated that experience in conducting triage assessments is an important factor for appropriate triaging (17). The study by Madani et al. recommends nurse managers select triage officers by considering the abilities and experience (18). According to the participants, triage is important in the ER as the first stage of hospital services and is crucial for initial management. In the ER, patients with various life-threatening conditions arrive and require immediate treatment. Prioritization is necessary when treating patients based on the severity of their illness (6). Although triage is used as a rapid assessment step in the ER, it can also cause delays in treatment due to a lack of resources, leading to overcrowded conditions, poor outcomes, frustrated patients, and staff fatigue and errors (6). A previous study considered several interventions to overcome long ER waiting times, including minimizing staff turnover, increasing the knowledge and abilities of staff through training, and reducing unnecessary actions such as duplicate patient documentation (7). The triage process requires rapid and accurate decisions; therefore, officers must have sufficient knowledge. Duko et al. emphasized that adequate knowledge of triage and clinical aspects of disease identification and emergency conditions are essential for effective and quality triage assessments (19).

Another study in a Tanzanian hospital found that a lack of knowledge caused assessments errors. Twenty-five percent of patients were placed in lower triage level zones and 42% in higher ones (20). Participants in our study agreed that a lack of in-depth examination during triage assessment causes errors, especially when the triage area is overcrowded and experienced triage officers are needed to quickly gather patients’ medical history and perform detailed examinations. This statement aligns with a study that showed inaccurate assessments of patient complaints result from a lack of knowledge and experience in identifying diseases and complaints (21). Health services must address patient safety. Errors in triage assessments must be avoided because they can compromise patient safety (22). Errors can result in under- or over-triaging patients, placing patients at risk, or resulting in unnecessary delays. Triage training should focus on identifying the causes of these errors to minimize negative impacts. Poor collaboration between triage officers can negatively affect the assessment results. Trust-building and conflict avoidance are crucial in the triage process. According to Welp and Manser, trust and respect among triage officers can improve patient safety and individual satisfaction at work (23). Leadership, self-confidence, and collaboration skills are essential for triage officers dealing with emergencies. Management, leadership, and coordination are crucial in supporting the collaborative abilities of emergency nurses (22). Other studies have also suggested that nurses lacking collaboration skills often struggle to handle situations effectively, particularly in crowded ERs, and tend to become hasty and anxious (11). During our FGDs, participants emphasized the significance of triage officers maintaining a professional appearance, which can instill patient confidence. According to a study by Porr et al., a good appearance can increase patient trust in triage officers (24). Most participants agreed that triage officers and medical staff should receive regular training to keep up with new developments in triage knowledge. One study found that the performance of cancer treatment staff declines after three months and thus ongoing training is needed (25, 26). Another study by Gerard stated that most nurses required regular training, as they forgot or did not practice aspects of their skills (27). Training used a web system to deliver materials and conduct tests. Online learning has been used to limit mobility during the pandemic. The web system for health science training is flexible, easy to access, and suitable for nurses (28, 29). However, connectivity issues are frequently encountered during online training, and it is important to communicate the minimum connection requirements for optimal training.This study showed that triage training can be conducted using a hybrid approach. Hybrid learning is a beneficial educational model, providing more flexibility and resilience than traditional-based instruction. The learning management system is an effective medium for triage training during the COVID-19 pandemic. Even in the post-pandemic era, many people, including health professionals, have become accustomed to the flexibility and convenience of hybrid learning during the pandemic. They may continue to prefer this mode of learning, so hybrid learning will likely continue to play an essential role in training, even after the pandemic has subsided. This study was conducted in a single hospital, which may limit the generalizability of the findings. The small sample size could also affect the ability to detect important effects. Future studies should be conducted with larger sample sizes and at multiple centers with different resources to gain a broader perspective.

Conclusion

Professionalism of the triage officer strongly affects the efficiency and accuracy of triage services. Experience and hard and soft skills reduce mis-triage incidents and increase patient safety. Regular triage training is essential for handling emergency situations effectively. Due to the limited mobility caused by the COVID-19 pandemic, a hybrid training approach was implemented to adapt to the situation and available resources, supported by reliable connectivity and a learning system. Regular triage training should be conducted to evaluate and update triage officers' skills and ultimately support their ability to conduct triage assessments.