Deanship of Graduate Studies

Al- Quds University

Nurses' Knowledge, Perception Regarding the

Implementation of Triage System in Pediatric
Emergency Department at Gaza Strip

Ahmed Waleed Hussein Abu Seda

M. Sc. Thesis

Jerusalem- Palestine

1441 / 2020
 Nurses' Knowledge, Perception Regarding the
Implementation of Triage System in Pediatric
Emergency Department at Gaza Strip

Prepared by
Ahmed Waleed Hussein Abu Seda

Bachelor Degree in General Nursing Sciences- Palestine

College of Nursing - Palestine

Supervisor: Dr. Mohammed Aljerjawy

A thesis Submitted in Partial Fulfillment of

Requirement for the Degree of Master of Pediatric
Nursing/ Faculty of Health Profession/ Al-Quds
University, Palestine

1441- 2020
Dedication

I dedicate this work to the Almighty Allah for preserving my life, ensure my

security in Gaza strip and gave me good Health and strength to be able to do

this work.

To my parents for their endless prayers and my family for their

encouragement. To my friends for supporting and encouragement.

To all martyrs and injuries in Palestine.

To every person help me to finish this work.

Ahmed w. Abu Seda

Declaration

I certify that this thesis submitted for the degree of master, is the result of my own

research, except where otherwise acknowledged, and that this study (or any part of the

same) has not been submitted for a higher degree to any other university or institution.

Signed:

Ahmed Waleed Abu Seda

Date: / /

i
Acknowledgement

First and last, all thanks to (Allah) for his support to complete this thesis, Grateful

appreciations are to my supervisor; Dr. Mohammed Aljerjawy for his expertise and

encouragement that helped me greatly to complete this work.

A lot of thanks to Al-Quds University and Faculty of Health Profession and grateful

appreciation to coordinator of Faculty of the Master Pediatric Program Dr. Hamza

Abdeljawad.

The thanks for Ministry of Health and for directors of nurses, head of nurses and all

nurses who work in governmental hospitals.

Also, the thanks reached to the arbitrators of my study:

1- Dr. Hamza Abdeljawad 2- Dr. Abdelmajeed Thabet 3- Dr. Khalil Shaiib

4- Dr. Abdelrahman Alhams 5- Osama Elyain

With my appreciation and respect Ahmed Abu Seda

ii
Abstract

Triage is an essential function of staff in emergency department. Nurses‘ knowledge about

triage is decision making, and effective decision-making can influence the health
outcomes of patients. The study aimed to assess the knowledge and perception of triage of
nurses about triage system in pediatric emergency departments at governmental hospitals
in Gaza Strip, and determine challenges to the implementation of triage system. The study
utilized descriptive, cross-sectional, analytical design. The sample of the study consisted
of 112 nurses (census) from eight pediatric emergency departments. For data collection,
self-administered questionnaire was developed by the researcher with response rate
93.9%. Pilot study was implemented on 10 questionnaires, and the Cronbach alpha for
reliability was 0.83 for knowledge domain, 0.75 for perception, and 0.65 for challenges.
The researcher used SPSS (version 22) for data analysis. Statistical analysis included
frequencies, means, standard deviation, (t) test, One-way ANOVA, and Pearson
correlation test. The results showed that 76.8% of study participants were male nurses,
67.3% were married, 66% have bachelor degree, 41.4% have an experience less than 3
years, 61.6% were staff nurses, and 42% are working mixed shifts (day, evening, night).
The results also indicated that 33% of nurses reported that they received training about
triage system. Nurses expressed above moderate (76%) knowledge about triage system,
high perception (81%), and moderate challenges (57%) to implement triage system in
pediatric emergency departments. Conclusion and recommendation: There were
significant negative relationship between perception and challenges. Factors that led to
higher knowledge about triage included training, have bachelor degree, being a nurse
manager, and being from EGH. While low knowledge found among participants from the
age group 28 – 38, from Gaza and the north. Higher challenges reported among single
participants, and living in Khanyounis and Rafah. No significant differences related to
gender, experience, and work shifts. The findings revealed the need for training programs
in order to improve nurses‘ knowledge and skills in performing triage of the patients at
pediatric emergency departments.

iii
Table of Contents
Declaration.............................................................................................................................. i
Abstract ................................................................................................................................. iii
Table of Contents ................................................................................................................. iv
List of Tables ........................................................................................................................ vi
List of Figures ...................................................................................................................... vii
List of Annexes................................................................................................................... viii
List Of Abbreviations ........................................................................................................... ix
Chapter One Introduction ................................................................................................. 1
1.1 Background ..................................................................................................................................... 1
1.2 Problem Statement ..................................................................................................... 3
1.3 Justification ................................................................................................................ 3
1.4 Research Objectives................................................................................................... 5
1.4.1 General Objective ................................................................................................ 5
1.4.2 Specific Objectives .............................................................................................. 5
1.5 Research Questions .................................................................................................... 5
1.6 Context Of The Study ................................................................................................ 6
1.7 Theoretical And Operational Definitions: ................................................................ 10
1.8 Conceptual Framework ............................................................................................ 11
Chapter Two Literature Review ..................................................................................... 12
2.1 Background .............................................................................................................. 12
2.2 Triage And Health Professionals ............................................................................. 13
2.3 Triage Scales ............................................................................................................ 14
2.4 Triage Outcomes ...................................................................................................... 15
2.5 Effect of Triage on Waiting Times .......................................................................... 16
2.6 Education For Triage ............................................................................................... 16
2.7 Triage Effect on Quality Improvement.................................................................... 17
2.8 International Studies ................................................................................................ 17
Chapter Three Materials And Methods .......................................................................... 34
3.1 Study Design ............................................................................................................ 34
3.2 Setting of The Study ................................................................................................ 34
3.3 Study Population ...................................................................................................... 34
3.4 Study Sampling and Sample Size ............................................................................ 35
3.5 Instrument of The Study .......................................................................................... 35
3.6 Reliability and Validity............................................................................................ 36
3.6.1 Validity .............................................................................................................. 36
3.6.2 Reliability .......................................................................................................... 36
3.7 Data Collection ........................................................................................................ 36
3.8 Eligibility Criteria .................................................................................................... 37

iv
 3.8.1 Inclusion Criteria: .............................................................................................. 37
3.8.2 Exclusion Criteria: ............................................................................................ 37
3.9 Pilot Study ............................................................................................................... 37
3.10 Statistical Management and Procedures .................................................................. 37
3.11 Ethical and Administrative Considerations ............................................................. 38
3.12 Period of The Study ................................................................................................. 38
Chapter Four: Results And Discussion .......................................................................... 39
4.1 Socio-Demographic Characteristics Of Study Participants ..................................... 39
4.2 Knowledge about Triage System ............................................................................. 43
4.3 Perception about Triage System .............................................................................. 45
4.4 CHALLENGES TO TRIAGE IMPLEMENTATION ............................................................. 47
4.4 Relationship between Knowledge, Perception, and Challenges .............................. 49
4.5 Relationship between Knowledge, Perception, Challenges, and Sociodemographic
Characteristics .................................................................................................................. 50
Chapter Five: Conclusion And Recommendations ........................................................ 62
5.1 Conclusion ............................................................................................................... 62
5.2 Recommendations: .................................................................................................. 62
References........................................................................................................................... 64
Annexes ............................................................................................................................... 70

v
List of Tables

Table (‎3.1): Distribution of study participants according to hospital .............................................. 35

Table (‎3.2): Reliabilities estimates for domains after pilot study.................................................... 36
Table (‎4.1): Distribution of study participants by work conditions ............................................... 39
Table (‎4.2): Knowledge about triage system among study participants ......................................... 43
Table (‎4.3): Perception about triage system among study participants .......................................... 45
Table (‎4.4): Challenges to triage system ........................................................................................ 47
Table (‎4.5): Relationship between knowledge, perception, and challenges to triage implementation
..................................................................................................................................... 49
Table (‎4.6): Relationship between knowledge, perception, challenges and gender ....................... 50
Table (‎4.7): Relationship between knowledge, perception, challenges and age ............................ 51
Table (‎4.8): Relationship between knowledge, perception, challenges and marital status ............ 52
Table (‎4.9): Relationship between knowledge, perception, challenges and place of residency .... 53
Table (‎4.10): Relationship between knowledge, perception, challenges and qualification ............ 54
Table (‎4.11): Relationship between knowledge, perception, challenges and job title .................... 55
Table (‎4.12): Relationship between knowledge, perception, challenges and experience in pediatric
ED ............................................................................................................................... 56
Table (‎4.13): Relationship between knowledge, perception, challenges and work shifts .............. 57
Table (‎4.14): Relationship between knowledge, perception, challenges and hospital .................... 58
Table (‎4.15): Relationship between knowledge, perception, challenges and previous triage training
..................................................................................................................................... 60

vi
List of Figures

Figure (‎2.1): Conceptual Framework .............................................................................................. 11

Figure (‎4.1): Distribution of study participants according to gender. ............................................. 40
Figure (‎4.2): Distribution of study participants according to marital status ................................... 40
Figure (‎4.3): Distribution of study participants according to place of residence. ........................... 41
Figure (‎4.4): Distribution of study participants according to qualification ..................................... 41
Figure (‎4.5): Distribution of study participants according to age ................................................... 42
Figure (‎4.6): Distribution of study participants according to years of experience .......................... 42

vii
List of Annexes

Annex 1: Questionnaire in Arabic ...................................................................................... 70

Annex 2: Helsinki Approval ............................................................................................... 74
Annex 3: Ministry of Health Approval ............................................................................... 75
Annex 4: Action Plan .......................................................................................................... 76

viii
List of Abbreviations
AAP American Academy of Pediatrics
ATS Australian Triage System
CI Confidence Interval
CPETS Chinese Pediatric Emergency Triage Scale
CTMS Computerized Triage Manchester Services
ECS ED Emergency Care Services Emergency Department
EGH European Gaza Hospital
EMS Emergency Medical Services
ESI Emergency Severity Index
ETAT Emergency Triage Assessment and Treatment
GDP Gross Domestic Product
GS Gaza Strip
HCPs Health Care Providers
HCWs Health Care Workers
IUG Islamic University of Gaza
KAP Knowledge, Attitude, Practices
LOS Length of Stay
MOH Ministry of Health
MTS Manchester Triage System
NGO Non-Governmental Organization
NICE National Institute for Health and Clinical Excellence
NSS Nursing School Shifa
NTS National Triage Scale
PCN Palestinian College of Nursing
PICU Pediatric Intensive Care Unit
RCN Royal College of Nursing
RN Registered Nurse
RR Respiratory Rate
SATA South Africa Triage System
SDI Standard Discharge Instructions
SPSS Statistical Package for Social Sciences
TATTT Toowoomba Adult Triage Trauma Tool
UCAS University College of Applied Science

ix
UK United Kingdom
UNRWA The United Nations Relief and Work Agency
USA United States of America
WB West Bank
WHO World Health Organization

x
1 Chapter One
Introduction

1.1 Background

Triage is an essential function of an Emergency Department (ED) and it is a term used to

describe the sorting of patients for treatment priority in ED Also, the purpose and function

of triage is to first identify patients with life-threatening or emergency conditions who

cannot wait to be seen and initiate appropriate interventions, and then allocate the patient

to the right area within the ED (Afaya et al., 2017).Triage at the Emergency Department

(ED) aims to prioritize pediatric patients when clinical demand exceeds capacity

(FitzGerald et al., 2010). As the burden on ED worldwide is steadily increasing, triage

remains a fundamental intervention to manage pediatric patient flow safely and to ensure

that pediatric patients who need immediate medical attention are timely treated,

particularly in case of overcrowding, therefore identifying pediatric patients at a high risk

of death is important in the ED to offer adequate treatment and to recognize patients in

need of more intensive management and possible admission to pediatric intensive care unit

(PICU) (Robert et al., 2014).

Triage is recognized as a central component of the ED and was first introduced in the 1950s

in the USA (Melot , 2015). More recently, the need for triage systems was also identified

in low-resource settings with reports showing that the process of triage can improve patient

flow, reduce patient waiting times, and decrease mortality rate in these contexts (Bruijns et

al., 2008).

A key goal of all publicly-funded health care systems is to deliver evidence-based care in

the most cost-effective setting while achieving high-quality outcomes. To this end,

diverting low acuity patients from the Pediatric emergency department (PED) to primary

1
care in the community is highly desirable. Lack of access to primary care is an obvious

barrier to reducing low-acuity PED visits; however, Farion et al., (2015) showed that even

among families with primary care providers, visits to the PED were common for low-

acuity health problems, as families over-estimated the seriousness of their child‘s

condition. Also, Early recognition and stabilization of acutely ill infants and children

improves outcomes in all settings, regardless of resources. When resources are constrained,

interventions which include the introduction of triage training and process, the use of

clinical practice guidelines and the supervision and monitoring of patients lead to reduced

mortality rates in critically ill children (Abdulmutalib et al., 2016). The acuity of patients

presenting to PED varies widely. Although many children require only basic care, those

with emergency medical conditions often experience delays in initial treatment.

Consequently, their conditions deteriorate, resulting in admissions that may have been

avoidable (Ayieko et al., 2011).

Nurses‘ knowledge and experience about triage have been cited as influential factors in

triage decision-making, many triage education programs are underpinned by the

assumption that knowledge acquisition will result in improved triage decisions. Therefore

the triage nurse‘s ability to make accurate clinical judgments about patient urgency and

their need for intervention are essential to the delivery of safe and effective emergency

care, including triage, is often one of the weakest parts of the health system in low-income

countries as compared to industrialized countries; but if well-organized it can be life-saving

and cost- effective care . On the other hand, there are many hospitals in low-income

countries lack a formal triage system. Clinicians usually see the patients on a ‗first-

come-first-served‘ basis, there is often no ED and patients are seen in either the wards or

the outpatient clinic when they arrive. This results in potentially deadly delays for critically

ill patients. Once a patient has been identified as being critically ill, there can be further

delays in initiating emergency treatment (Robert et al., 2014).

2
1.2 Problem statement

From the researcher experience with in three years of working at Nasser Pediatric ED in

Gaza Strip hospitals, the researcher observed that it was very crowded especially after 2:00

PM, when the United Nations Relief and Work Agency (UNRWA) and governmental

primary health care centers are closed with overcrowded conditions and the length of child

stay at ED that sometimes reach too long hours to see doctor. The number of patients

arriving at PEDs has increased over the past few years in Gaza partly because of self-

referrals, and for economic reasons include low salaries because the nonprophetic care

services at the governmental hospitals this reason resulting in overcrowding at PED. This

raised a concern of the need for a system that prioritizes patients in the order of urgency.

Nurses weak knowledge and wrong perception about triage system lead to wrong

implementation that usually see the patients on afirst-come-first-served basis. This practice

does not create room for critical and emergency cases to be managed immediately.

Presently most of PEDs at Gaza hospitals have triage system that un implemented or

wrongly used by nurses and doctors because of deficiency of knowledge or wrong

perception about triage rules, colors and waiting time.

1.3 Justification

Few studies have analyzed the nurses‘ knowledge and perception of nurses about

emergency triage care services in pediatric emergency settings. Also, the importance of

studying the implementation of the emergency triage system in the emergency department

in the Gaza Strip as a special due to the overcrowding of cases in the PEDs, and also

because of the difficult and exceptional conditions experienced by the health system in the

Gaza Strip due to lack of professional staff, equipment and capabilities. The result of this

study will help to improve the quality of care at pediatric emergency departments by

3
discover the need for implementation of pediatric triage system, reach family satisfaction,

and could provide guidelines for another emergency department concerning the

implementation of a triage system. The need of emergency triage system implementation in

these departments is shown here, because it has a direct effect on the quality of health care

provided and on patient and family satisfaction about health care service at the hospitals of

the Palestinian Ministry of Health. Locally, to date, there was no previous studies related to

this topic and it‘s the first time to accomplish this research among pediatric emergency

nurses in Gaza strip. Globally, there were several studies dealt with this subject in many

countries like United Kingdom, south Africa, United Arab Emirate, and other countries.

So, the researcher wants to determine whether the implementation of the Triage System in

the pediatric emergency department enhanced the quality of emergency care, according to

the perceptions of nurses working in this departments. The result also enhances the triage

skills, practice and knowledge of nurses, continuing education and training courses related

to triage and other nursing skills advanced management of medical emergencies are key

aspects to improve quality care and patient safety. Receptionists and administrative staff

members should be orientated about the triage process. Future studies should conduct two

investigations, before and after the implementation of the PED triage, in a specific unit.

This will produce comparative data and enable the calculation of correlation statistics for

new studies. Finally, the findings of this study could serve as guidelines for research prior

to the future implementation of the same or similar triage systems in other emergency

units.

4
1.4 Research objectives

1.4.1 General objective

The study aim to assess nurse's knowledge and perception regarding the implementation of

triage system in pediatric emergency department at Gaza Strip.

1.4.2 Specific objectives

1- To determine the nurses' knowledge about the triage of patients.

2- To identify the nurses' perception about triage system.

3- To identify the challenges for implementation of pediatric triage system

4- To Investigate the relationship between nurse's knowledge level and their perception

about triage implementation.

5- To investigate the relationship between nurse's knowledge, perception and their

qualification

6- To observe the relationship between nurse's knowledge, perception and their

sociodemographic characteristics

7- To suggest recommendations for t h e further improvement of the newly implemented

triage system.

1.5 Research questions

1- What is the level of nurses' knowledge about the implementation of triage at PED?

2- What is the level of nurses' perception about the implementation of triage at PED?

3- What are the challenges for triage implementation at pediatric ED?

4- Is there a relationship between nurses' knowledge, perception about triage

implementation?

5
 5- Is there a relationship between nurses' knowledge and their qualification?

6- Is there a relationship between nurses' knowledge and their sociodemographic

characteristics?

7- Is there a relationship between nurses' perception and their sociodemographic

characteristics?

8- Is there a relationship between nurses' perception and their triage challenges?

9- Is there a relationship between nurses' knowledge and triage course attending?

1.6 Context of the study

- Sociodemographic context

Palestine lies within an area of 27,000 square kilometers (Km2), expanding from Ras al-

Naqoura in the north to Rafah in the south (Annex 1). Palestinian territories is divided into

three areas separated geographically; the West Bank (WB) 5.655 Km2, Gaza Strip (GS)

365 Km2 and East Jerusalem. Based on estimates prepared by the Palestinian Central

Bureau of Statistics (PCBS), the estimated population in Palestine is approximately 4.95

million. Male gender consists of 2.52 million while female gender consists of 2.43 million.

The estimated population in the WB is about 3.01 million, including 1.53 million males

and 1.48 females, while the population in GS is estimated to be over 2 million, including

approximately 988,000 males and 956,000 females. The population density (capita/km2) is

823 (532 in WB and 5324 in GS) (PCBS, 2018). Latest reports in August 2018

demonstrated that total population is 5,065 million with male to female ratio 103.4:100,

and 73.6% of the population is urban, and the median age is 19.6 years

(www.worldometers, 2018). Natural increase rate accounts for 2.8 (2.5 in WB and 3.3 in

GS), life expectancy for males 72.1 years and for females 75.2 years, average household

size 5.2 (4.8 in WB and 5.7 in GS), total fertility rate 4.1 (3.7 in WB and 4.5 in GS), infant

6
mortality rate 18.2 (17.0 in WB and 19.6 in GS (PCBS, 2018).

- Economic context

The Palestinian economy suffers from continuous pressure caused by long-term siege,

imposed by Israeli occupation for more than 12 years. Economic status in the Palestinian

territories is very low. A significant increase in poverty rates occurred in GS from 38.8%

in 2011 to 53% by the end of 2017 , Also Gross Domestic Product (GDP) is estimated

about 440.2$ (576.0 in WB and 248.7 in GS), unemployment rate accounted for 18.2% in

WB and 41.7% in GS and for female's unemployment rate is 44.7% (29.8% in WB and

65.2% in GG) (PCBS, 2018).

- Health care system in Palestine

The Palestinian health system consists of different parties. The main parties that offer

health services are the MOH, Non-Governmental Organization (NGOs), UNRWA, the

military health services, and the private sector. The total number of hospitals in Palestine is

83 hospitals, 51 of them in WB including east Jerusalem and 32 in GS. The number of

hospitals owned by MOH in Gaza strip is 13 hospitals, 16 for NGOs, 2 for the Ministry of

Interior and National Security and 1 for the private sector. The number of hospital beds in

the Gaza Strip reached 2,943 beds (2,240 beds belonging to the Ministry of Health, 526

beds belonging to non-governmental institutions, and 177 beds belonging to the Ministry

of Interior and National Security).The number of physicians working in different centers

and units of MOH is 3100 physicians, with 14.6 physicians per 10,000 population of

Palestine in GS, and the number of nurses working in MOH in GS is 3682 nurses

representing 25.1 % of total employees in MOH, with 21.2 nurses per 10,000 population of

Palestine in GS .The number of visitors to emergency departments in 2017 was 1,402,222

7
visitors (MOH, 2018).

- Martyr Mohammed Al-Durra Hospital

Martyr Mohammed Al-Durra Children's Hospital is a hospital that provides general

pediatric services in Gaza City. The hospital has a clinical capacity of 100 beds. It is

located in Salah El-Din Street. It was built in 2000 on an area of 1600 square meters,

serving the areas of Al-Shuja'iya, Al-Shaaf and Al-Daraj neighborhood. Al-Zaytoon and

Al-Tuffah neighborhood, the hospital consists of four departments: a pediatric emergency

department and two internal department for children and intensive care. Martyr

Mohammed Al-Durra Children's Hospital is the first center for pediatric cardiology in

Palestine in addition to general pediatric services and intensive care (MOH, 2018).

- Al-Nasr Hospital

Established in 1962, Al-Nasr Children's Hospital, with an area of 4400 m2, is the oldest

and largest children's hospital in the Gaza Strip. It is located in Al-Nasr neighborhood, and

it serves a large area of Gaza City and some of its services extend to the central and

northern area in the Gaza Strip, with a capacity of 132 beds and a total hospital staff of 294

employees, the hospital's mission is to provide health services to children from birth to 12

years of age (MOH, 2018).

- Al-Aqsa Martyrs Hospital

Al-Aqsa Martyrs Hospital is the only governmental hospital in the central region, serving

more than 300,000 people. General hospital provides medical and surgical services,

women, obstetrics and pediatrics. The population of Middle governorate has a clinical

capacity of 129 beds, of which 103 beds are reserved for hospitalization. The staff is 562

8
employees of all categories (MOH, 2018).

- Nasser Medical Complex

Medical Complex includes Naser hospital, which is dedicated to surgery, internal

medicine, Al-Tahreer hospital for women, childbirth and children, and Al Yassin hospital,

it located in Khan Younis. Khan Yunis governorate has a total clinical capacity of 322

beds, with a total of 769 employees. Al-Tahreer Hospital was opened in 1999 and covers

an area of 1800 square meters. The hospital has a pediatric emergency department, and two

internal department for children, it includes 64 beds for children, It also has a special care

baby unit for newborns. It also has a maternity department with 90 beds for maternity

cases, it also has two rooms for obstetrics and gynecology (MOH, 2018).

- European Gaza Hospital

European Gaza Hospital is located in Khan Younis governorate. The total area of the

hospital buildings is 20,000 square meters. Gaza European Hospital is a distinguished

center providing medical services in the second and third level of the southern region. The

hospital serves a population of 500,000 following international standards of medical care.

The European Gaza Hospital is a model of administrative operations, particularly in the

optimal use of information technology and the development of comprehensive medical

records management and financial management systems. A large public hospital with a

total clinical capacity of 256 beds, of which 203 beds are allocated for overnight use. The

population in the southern governorates of the Gaza Strip is particularly distinguished by

providing heart catheter service to all governorates of the Gaza Strip. The total number of

hospital staff is 781 employees (MOH, 2018).

9
1.7 Theoretical and operational definitions:

Triage ‗Triage‘ is derived from the French word ‗trier‘ which means to ‗pick or to sort‘.

Patients or problems are thus sorted according to their degree of seriousness – their need

for treatment – and the available resources to offer the treatment (Augustyn et al., 2009). In

this research, ‗triage‘ is the prioritizing (by an assigned nurse or doctor) of patients who

arrive at the participating emergency unit

Emergency ‗emergency‘ means any physical, psychological or medical condition admitted

to the emergency unit. The emergency unit refers to a well- equipped level II accident and

emergency facility of a private hospital with a two-bed resuscitation room with overhead

gantry x-rays; one-bed isolation room; two-bed overnight room; one general emergency

room area with eight beds/patient cubicles; triage room two doctors‘ consultation rooms

and a reception/waiting area with 34 chairs (Augustyn et al., 2009). The researcher adopt

this definition as operational definition

Knowledge: Knowledge is often defined as a belief that is true and justified. This

definition has led to its measurement by methods that rely solely on the correctness of

answers. A correct or incorrect answer is interpreted to mean simply that a person knows

or does not know something (Hunt, 2010). The researcher adopts this definition as

operational definition, and it will be measured by true and false question.

Perception: Perception can be defined as our recognition and interpretation of sensory

information. Perception also includes how we respond to the information. Or can think of

perception as a process where person take in sensory information from our environment

and use that information in order to interact with our environment. Perception allows us to

take the sensory information in and make it into something meaningful, (Haghigh et al.,

10
2017) in this research perception demonstrate nurse's recognition about triage

implementation, and it will be measured by eleven Likert scale question.

Challenges: challenges always defined as something new and difficult which require great

effort and determination or ideas, also defined people you question their truth, value or

authority (Haghigh et al., 2017). In this research the researcher defined challenges as all

things that face or defense and interrupts the implementation of pediatric triage system.

1.8 Conceptual Framework

Challenges

- lack of previous study

- lack of equipment
- shortage of staff

Nurses Knowledge
Nurses Perception Triage Triage scales
triage effect on quality Implementation Waiting time
nurse triage role
Different colors
triage mechanism

Source: (Melot, 2015)

Figure (‎1.1): Conceptual Framework

In this study the independent factor was (nurse's knowledge, perception and triage

challenges). Also, the dependent variable was (triage implementation). The researcher

mentions that on the figure above triage challenges as: lack of previous study, lack of

equipment and -shortage of staff. (Melot, 2015).

11
2 Chapter Two
Literature Review

2.1 Background
The process of triage decision-making is influenced by three interrelated factors: the

characteristics of the patient, the triage decision-maker and the health care setting. Triage

is important for redistributing and reducing waiting times and admission rates, increasing

the efficiency and effectiveness of the ED, enhancing patient and family satisfaction,

improving the quality of health care, managing funding and assessing the effectiveness of

ED activities, While the importance of triage in the ED has been recognized for some time

in developed countries, less developed countries, including those of the EMR, are not

utilizing the full potential of this health developmental trend. The EDs of psychiatric

hospitals especially have much progress to make to realize the benefits of triage (Whitby et

al., 2015)

12
2.2 Triage and health professionals
Triage is usually performed in the ED by nursing staff who allocate a triage designation

and initiate emergency care before the patient is examined by a doctor. Triage may be done

by ED physicians as well. In prehospital disaster sites, ambulance personnel also need to

use triage to prioritize multiple cases for immediate mass evacuation for emergency

medical help in nearby hospitals. Triage nurses usually have advanced training in decision-

making. They have been shown to have the necessary skills to make appropriate triage

decisions and provide a highly effective service to ED patients in health care settings, also

Many patients arriving at the ED have complex problems that need several investigations,

procedures or consultations. Triage nurses can validly and reliably estimate the complexity

of such cases, guide ED workflow and casemix system analysis (Cioffi, 2014).

In a study of decisions about appropriate care provider, priority rating and preliminary

investigations for ambulatory patients the level of agreement between the triage nurses and

physician observers was 81% and between the triage nurses and treating physicians was

94%. Triage nurses identified a greater number of patients (19%) as having emergency

problems (17%), and fewer patients (45%) as having problems of a non-urgent nature

compared with physician observers (47%). The study concluded that experienced

emergency nurses in the role of triage were safe, efficient and cost-effective, with

statistically significant levels of safety and accuracy of priority rating when compared to

triage physicians and treating physicians. Also, the increasing use of triage and the

increasing numbers of ED visits by patients raises the important issue of a parallel need to

increase the number of triage nurses in EDs (O‘Brien, Irvin and peereboom, 2010)

13
2.3 Triage scales

Australian Triage Scale (ATS)

Different triage scales have been developed to help health professionals to classify ED

patients consistently and to achieve acceptable health outcomes. Triage scales usually have

3 to 5 categories, with algorithms or protocols or sentinel diagnoses as the anchor points

for making decisions, supported by triage guidelines and procedures. They are now

generally supported by computer-based programs and web-sites which are faster and more

effective aids to prioritization and decision-making. The most commonly used scale is the

Australian Triage Scale (ATS), which has 5 categories with their corresponding level of

treatment acuity (scale table). The ATS is derived from the National Triage Scale (NTS)

for Australasian emergency departments, the 2 scales differing in the description and

allocation of the 5 categories. In a study in Belgium, the NTS was reported to have good

predictive validity (Van Gerven et al., 2001). This triage scale who implemented of gaza

ED. Also, recently used at PED.

(Yousif et al. 2015) reported that use of the ATS had a significant impact on the triage

distribution of ED patients compared with the NTS, with 28% and 24% increases in

patients with categories 2 and 3 respectively and 15% and 67% decreases in patients with

categories 4 and 5, respectively. The ATS is therefore better suited to meet performance

criteria and case mix assessment.

Toowoomba Adult Triage Trauma Tool (TATTT)

Another scale from Australia is the Toowoomba Adult Triage Trauma Tool (TATTT),

which is a computerized algorithmic clinical-decision support tool designed for use on a

handheld personal computer. It is well accepted by users and is seen as a viable alternative

14
to current triage practice. The TATTT incorporates ATS categories but largely replaces the

associated clinical indicators and provides an evidence-based valid and consistent method

of triage assessment and categorization of trauma patients (Dann, 2005).

Manchester Triage System (MTS)

The other international triage scales in common use are the Manchester Triage System

(MTS) with its new updated version, the Emergency Severity Index (ESI) used in the

United States of America and the Canadian Emergency Department Triage and Acuity

Scale (CTAS) and its web-based triage tool (etriage), ambulance personnel use disaster

triage based on the Homebush Triage Standard Taxonomy in prehospital settings, which

includes battlefields, accident and trauma sites and places of massive fires also mental

health triage scales have also been developed for triaging ED patients with mental

disorders because the triage scales mentioned above have little capacity for triaging mental

patients. Psychiatric nurses have been shown to use these scales effectively in the EDs of

psychiatric hospitals (Broadbent et al., 2007).

2.4 Triage outcomes

There are two stages to the nurse triage process: first, the triage assessment which leads to

allocation of a triage category and the subsequent processing of the patient; and secondly,

the initiation of nursing interventions to facilitate emergency care with a possible reduction

in the patient‘s discomfort. These triage decisions are linked with three types of outcome:

―correct‖ or ―expected‖ triage, ―over-triage‖ and ―under-triage‖. Correct triage by a nurse

is associated with a positive health outcome because the patient is evaluated by a doctor

within a suitable timeframe. Over-triage and under-triage indicate that triage nurse

allocated a triage category of a higher or lower acuity than required respectively. Outcomes

associated with over- or under-triage result in inappropriate allocation of ED resources,

15
prolonged waiting times for patients, and development of dangerous complications or

prolonging suffering. Notably, funding models or incentive programs for triage are

considered unethical (Gerdtz and Bucknall, 2010).

2.5 Effect of triage on waiting times

Nurse triage aims to redistribute the workload of the ED. The key issue is not increasing or

reducing waiting times overall but the effectiveness with which triage nurses allocate

shorter waiting times to the highest priority patients, thus redistributing patient waiting

times according to need. Waiting times in the ED affect patients‘ satisfaction with care but

may also have serious complications that adversely affect health outcomes. Prolonged

waiting times at triage sites are the most common reason for patients‘ and families‘

dissatisfaction with ED care. Accordingly, patients need to understand, perhaps via

educational campaigns, which medical problems are appropriate to present to the ED and

also be informed about the waiting times that correspond to the category of urgency they

are allocated (McMillan et al., 2014).

2.6 Education for triage

According to many studies, specialty education and continuing training in triage are the

cornerstones of the triage system and contribute considerably to the correct triage decisions

that are essential for good health outcomes. Continuing training but not experience was

found to influence triage decision-making, so Prior to adopting a triage role, nurses should

have both adequate specialist training and experience in the triage system .Studies in the

United States and Australia concluded that triage nurses have wide variability in their

degree of experience, preparation and orientation for the triage role, and insufficient

education and training. Hospitals also vary in their requirements for training and

experience before triage duties are performed. In view of the variability in triage training

16
and experience, there is a worldwide need to develop uniformly tailored triage education

curricula and triage guidelines, as well as continuing training and research in triage

systems. Triage guidelines coupled with triage education and training helps triage nurses to

prioritize ED patients in all health care settings including psychiatric EDs. No triage

guidelines, however, are perfect in predicting which patients are true emergencies (Kelly

and Richardson, 2010).

2.7 Triage effect on quality improvement

The quality measures for triage systems that have been explored in several studies include

the reliability of triage rating scales, waiting times, admission rates, accuracy of allocation

of categories and rates of sentinel events/diagnoses (outcomes unrelated to the natural

course of the patient‘s illness or underlying condition). Notably each quality indicator has

some disadvantages, such as the use of sentinel diagnosis, which can be made only after

extensive interviewing and evaluation, which adversely affects waiting times.

Inconsistency in application of various triage scales is another concern for quality

improvement in triage systems. Quality standards in ED can be maintained and enhanced

by audits of the triage system. Notably, a study of the resource implications of nonurgent

patients in the ED showed that 7.3% of all patients requiring admission came from the

group identified as nonurgent by the CTAS triage system and hence strategies diverting

them elsewhere might be unsafe and were unlikely to improve access for more urgent

patients (Broadbent et al., 2007).

2.8 International Studies

Afaya et al., (2017) conducted a study was "Perceptions and Knowledge on Triage of

Nurses Working in Emergency Departments of Hospitals in the Tamale Metropolis, Ghana

"The study aimed to assess the perceptions and knowledge of triage of nurses working in

17
the ED of hospitals in the Tamale Metropolis, Ghana. The study revealed that 62.6% of the

respondents were knowledgeable about triage by correctly answering more than 50% of the

questions, in the self-administered questionnaires. Majority of nurses (96%) in the ED of

the various hospitals had a very good perception about the importance of triage to the

patient, care provider and the country at large. Current findings showed that as the nurses

had increased years of working experience their triage knowledge level also improved. The

current study findings revealed a little above average percent score (62.6%) about triage

knowledge among nurses. To improve on this, workshops/in service training should be

carried out, followed by continuous professional development on a regular basis for nurses

in the ED.

Hammad et al, (2017) conducted a study was " Emergency nurses‘ knowledge and

experience with the triage process in Hunan Province, China" A sample of 300 emergency

nurses was selected from 13 tertiary hospitals in Changsha and a total of 193 completed

surveys were returned (response rate = 64.3%). The result of the study is Just over half

(50.8%) of participants reported receiving dedicated triage training, which was provided by

their employer (38.6%), an education organization (30.7%) or at a conference (26.1%).

Approximately half (53.2%) reported using formal triage scales, which were

predominantly 4- tier (43%) or 5-tier (34%). They concluded that the findings highlight

variability in triage practices and training of emergency nurses in Changsha. This has

implications for the comparability of triage data and transferability of triage skills across

hospitals.

Robert et al., (2014) conducted a study " Assessment of knowledge and skills of triage

amongst nurses working in the emergency canters in Dar es Salaam, Tanzania" The

purpose was to assess the triaging knowledge and skills of nurses working in the ECs in

18
Dar es Salaam, Tanzania. The Results was: Thirty three percent (20/60) of the respondents

were not knowledgeable about triage. Thirteen percent of the respondents reported that

although they had attended workshops, there had been a lack of information on how to

triage patients. More than half (52%) of the respondents were not able to allocate the

patient to the appropriate triage category. Fifty eight percent (35/60) of the respondents had

no knowledge on waiting time limits for the triaged categories. Among the four hospitals

observed, only one had nurses specifically allocated for patients‘ triage. The respiratory

rate of patients was not assessed by 84% of the triage nurses observed. No pain assessment

was done by any of the triage nurses observed. Only one out of four ECs assessed had

triage guidelines and triage assessment forms. Also, Nurses who participated in this study

demonstrated significant deficits in knowledge and skills regarding patients‘ triaging in the

EC. To correct these deficits, immediate in-service training/education workshops should be

carried out, followed by continuous professional development on a regular basis, including

refresher training, supportive supervision and clinical skills sessions.

Duko et al., (2019) conducted a study "Triage knowledge and skills among nurses in

emergency units of Specialized Hospital in Hawassa, Ethiopia the result of the study was:

Among the study participants, 57.4% were female and 87% were in age group of ≤ 30

years. 51.5% had low triage knowledge scores, with the mean score being 9.54

(SD = 2.317), 76.2% perceived their overall triage skill to be at good level, with mean

score 95.75 (SD = 9.562). Working experience of study participants (χ2 = 15.204, p < .01),

Educational level of study participant (χ2 = 22.148, p < .01) and triage experience

(χ2 = 13.638, p < .01) were factors associated with triage knowledge. Working experience

(χ2 = 7.944, p < .05) and triage experience (χ2 = 6.264, p < .05) were factors associated

with triage skill.

19
Aghababaeian et al., (2017) conducted a study was" Evaluating Knowledge and

Performance of Emergency Medical Services Staff Regarding Pre-Hospital Triage" the aim

of the study is to determine the knowledge and performance of EMS staff regarding

START pre-hospital triage in 2016. The result: 117 individuals with the mean age of 33.21

±6.08 years and mean job experience of 7.35 ± 4.32 years participated all of whom were

male. Mean knowledge of the studied population regarding triage was average (mean

score: 9.44) and their performance score revealed that their performance was also average

(mean score: 9.58). they Concluded that: Based on the findings of the current study,

knowledge and performance of EMS staff in north of Khuzestan province was average

regarding pre-hospital triage.

Haghigh et al., (2017) conducted a study was " A Survey on Knowledge Level of the

Nurses about Hospital Triage‖: Results: Finally, the knowledge of triage in nurses from

different areas showed that 36 nurses (51.4%) had low level while only 31 nurses (44.3%)

had a moderate level of knowledge about triage. They Concluded that: Awareness of ED

Nurses who were involved in the Triage of Patients were assessed as undesirable. The

result was: requires emergency department in the use of a valid and reliable scale to

increase consensus in decision-making with equipment that train, manpower and use of

equipment necessary for triage.

Küçükoğlu et al., (2017) conducted a study was "evaluation of the knowledge of triage

among nurses working in emergency department " This study was conducted to measure

the level of knowledge of triage among nurses working in pediatric emergency and general

emergency departments. The results were: In the study, the vast majority of nurses stated

that they did not receive triage education during (51.3%) and after (72.1%) their college

education. A statistically significant difference was found between the education level of

20
the nurses and their triage practices (p<0.05). It was found that 72.7% of the nurses

did not consider themselves qualified to perform triage, and 68.2% believed that triage

was among the duties of emergency care nurses. It was also determined that the physical

environment of the emergency department, the ability of personnel to triage and the

absence of specialist physicians and nurses were factors affecting triage practice (p<0.05).

they Concluded that: It was determined that the majority of nurses working in emergency

departments did not receive triage education, did not consider themselves competent on

triage and that triage practice should be supported through in-service training.

Mistry et al., (2018) they conducted a study " Nursing Perceptions of the Emergency

Severity Index as a Triage Tool in the United Arab Emirates. The result was :Interview

coding revealed 7 core themes related to use of the ESI (frequencies indicated in

parentheses): ease of use (90), speed and efficiency (135), patient safety (12), accuracy and

reliability (30), challenging patient characteristics (123), subjectivity and variability (173),

and effect of triage system on team dynamics (100). Intercoder agreement was excellent

(Cohen‘s unweighted kappa = 0.84). Subjectivity and variability in ESI score assignment

consistently emerged in all interviews and included variability in number and use of

resources, definition of ―high risk,‖nursing experience, and subjectivity in pain assessment.

They concluded that Contribution to Emergency Nursing practice: This qualitative analysis

of nursing perceptions of the emergency severity index (ESI) highlights the importance of

nursing input when implementing triage systems and describes perceived barriers and

strengths when using the ESI. Also, Knowledge of these specific factors may prove useful

in the development and implementation of triage systems in emergency departments

around the global.

21
Hussein and Hassan (2019) conducted a study " Effectiveness of Education Program in

Nurses' Practices about triage system in Emergency Department at Qalat Salih Hospital

"The aim of the study is to assess the effectiveness of an educational program on Nurses'

Practices about the triage system in Emergency department of Qalat Salih Hospital. the

results was: there were highly significant differences between pre and post-tests in the

study group in overall main domains related to nurses' practices they concluded that : the

effectiveness of educational program regarding nurses' practice concerning the triage

system in emergency department of Qalat Salih Hospital is significance and there are large

differences in pre-test than post-test in improvement the nursing staff regard to program of

the triage system. Also, the Recommendation was: The nurses' staff can be encouraged and

motivation for being participated in the special training programs and conference with the

triage system specialists who have long experience in practices of the triage procedure to

fulfil the nurses' needs related the triage system in their practices.

Lin et al., (2016) conducted a study " Implementation of a Pediatric Emergency Triage

System in Xiamen, China " The aim of this study was to evaluate the clinical value of a

new five-level Chinese pediatric emergency triage system (CPETS), modeled after the

Canadian Triage System and Acuity Scale In this study, we compared CPETS outcomes in

our PER relative to those of the prior two-level system. they concluded that: Implementing

the CPETS improved nurses‘ abilities to triage severe patients and, thus, to deliver the

urgent treatments more quickly. The system shunted nonurgent patients to outpatient care

effectively, resulting in improved efficiency of PER health-care delivery.

Genisca et al., (2018) conducted a study was "Healthcare Provider Attitudes toward the

Emergency Triage System in Belize" the aim of the study: To explore healthcare

providers‘ (HCP) attitudes toward the current triage system prior to national pediatric

22
triage implementation. The result: 16 HCPs (7 physicians and 9 nurses) participated after

ETAT training and 24 HCPs (15 physicians and 9 nurses; 11 [68%] from first focus

groups) participated one year later. The following principal themes emerged regarding

current triage systems: The initial groups stressed (1) the importance of triage education

and implementation to standardize and improve communication by using a unified

language between HCPs (2) desire to implement a simple, low-resource pediatric-specific

triage system and (3) major limitations of ESI included the difficulties of assessing

pediatric patients due to its complexity and lack of pediatric specific criteria as well as

dependence on equipment that is not consistently available. they expressed interest in

developing a triage system based on ETAT. Conclusions: Participants feel that triage

education and implementation is essential to improve communication and pediatric

emergency care and agree that a national pediatric triage system would be beneficial. Prior

to triage implementation all staff should be educated in the new process. When choosing

which system to use a simple, low-resource pediatric- specific system, like ETAT, may

improve utilization by staff providing faster recognition of and improved care for acutely

ill children. These beliefs should be considered when addressing triage implementation.

Abdoos et al, (2016) conducted a study " Impact of Training on Performance of Triage: A

Comparative Study in Tehran Emergency Department ". they assessed the effect of training

of triage nurses in Tehran Emergency Department on efficiency and accuracy of triage

decision making. Findings: The total frequency of dispatches based on new international

guideline was significantly lower than based on the routine protocol (84% vs. 46%)

(P < .001). In addition, the proportion of correct dispatches was found to be significantly

higher than those by the untrained group (75% vs. 20%) (P < .001). Further, frequency of

correct triage by trained group turned out to be significantly higher than by the untrained

group (80% vs. 30%) (P <.001). They Concluded that: Our study provides direct evidence

23
for the positive impact of updated training on improved performance of triage process and

encourages similar interventions to achieve higher efficiency in emergency departments.

Akinaga et al., (2017) conducted a study " Study on Triage Education for Nursing

Students" The purpose of this study is retrospectively to examine some mis-categorized

cases to identify causes of triage errors, and thereby inform the future design of courses for

triage education( START is a system of primary triage performed on casualties at the scene

of a mass-casualty incident. The results of the study showed that most students were likely

to answer the triage questions largely based on their perception of visual information (such

as video images) rather than on triage criteria.

Sherafat et al., (2019) conducted a study "The Experiences of Healthcare Staff about

Triage in Emergency Departments: A Qualitative Study "this study was conducted to

investigate the role of different underlying factors in triaging emergency patients through a

qualitative approach. The result: Four categories of profit triage, exhibitive triage,

enigmatic, and tentative performance triage were drawn from the data, collectively

comprising the main theme of responsibility-evading performance. They concluded that:

The dominant approach to the triage in the emergency departments in a central city of Iran

is responsibility evasion; however, the triage is performed tentatively, especially in critical

cases. To achieve a better implementation of triage, consideration of the underlying factors

and prevention of their involvement in triage decision-making is necessary.

Recznik and Simko (2018) conducted a study " Pediatric triage education: An integrative

literature review "The objective of this study was to review the currently published

literature on the topic of pediatric triage education. The result was: A wide variety of

pediatric triage educational methods exist, but studies with the highest-quality ratings most

often used simulation programs or a standardized curriculum. Although there was a good

24
deal of heterogeneity in terms of the outcomes measured, the accuracy of triage improved

following educational interventions. they concluded that: Additional research is needed to

compare different methods of pediatric triage education directly. Emergency nurses should

be aware that pediatric triage is a high-risk event, and some educational methods may have

advantages over others. In addition, although retention of pediatric triage skills is affected

by the method and timing of pediatric triage education, emergency nurses should remain

aware that improved pediatric triage skills could lead to improved pediatric outcomes, and

target this as an area for further research.

Allen et al., (2015) conducted a study " Accuracy and interrater reliability of pediatric

emergency department triage" the aim of the study: To determine the accuracy and

reliability of triage of children in public hospital EDs using the Australasian Triage Scale

(ATS). The result of the study: Triage nurses correctly assigned triage scores to an average

of 5.3 of nine pediatric clinical scenarios. Accuracy in specific hospitals ranged from a low

of 15% on one scenario, to 100% accuracy on a different scenario at a different hospital.

Interrater reliability within and across the EDs studied was found to be kappa = 0.27. Both

accuracy and interrater reliability were marginally higher at the specialty pediatric hospital.

They concluded that: Our findings demonstrate inconsistencies in the accuracy and

reliability in which sick children presenting to EDs receive triage scores both within and

across hospitals. These results suggest the need for improvements either in current triage

nurse training or training resources. Use of the ETEK alone has not resulted in high levels

of pediatric triage accuracy or reliability.

Sara et al., (2018) conducted a study "A descriptive study of registered nurses‘ application

of the triage scale RETTS©; a Swedish reliability study" the aim of the study was to

determine the reliability of application by registered nurses of the triage scale in two

25
Swedish emergency departments. The result of the study: The RNs allocated 1281 final

triage levels. There was concordance in seven (15%) of the scenarios, and dispersion over

two or more triage levels in 39 (85%). Dispersion across the stable/unstable patient

boundary was found in 21 (46%) scenarios. Fleiss κ was 0.562, i.e. moderate agreement.

They concluded that: The inability of the triage scale to distinguish between stable/unstable

patients can lead to serious consequences from a patient safety perspective. No general

pattern regarding concordance or dispersion was found.

Cristina et al., (2018) conducted a study "Configurations of factors affecting triage

decision-making". The purpose of this paper is to explore the configuration of factors

affecting the accuracy of triage decision-making. The results of this study show that the

interplay between individual and contextual/organizational factors determines the

emergence of errors in triage assessment. Furthermore, there are some regularities in the

patterns discovered in each of the investigated organizational contexts. These findings

suggest that we should avoid isolating individual factors from the context in which nurses

make their decisions. The value of the study: Previous research on triage has mainly

explored the impact of homogeneous groups of factors on the accuracy of the triage

process, without considering the complexity of the phenomenon under investigation. This

study outlines the need to consider the not-linear relationships among different factors in

the study of triage‘s decision- making.

Delnavaz et al., (2018) conducted a study "Comparison of scenario-based triage education

by lecture and role playing on knowledge and practice of nursing students"The objective of

this study was to compare the effect of educating emergency severity index (ESI) triage

using lecture and role-playing on the knowledge and practice of nursing students. The

results showed the effectiveness of both educational methods on students' learning.

26
However, the role-playing method was more effective than the lecture method and is

recommended for triage education. In addition, according to the importance of triage,

developing the theoretical and practical education courses for nursing students is

recommended.

Jordi et al., (2015) conducted a study "Nurses‘ accuracy and self-perceived ability using

the Emergency Severity Index triage tool": a cross-sectional study in four Swiss hospitals.

They concluded that Low accuracy of ESI score assignment was observed when nurses

scored an ESI for 30 standard written case scenarios, translated into nurses‘ native

language, despite a good inter-rater reliability and high nurse confidence in their ability to

apply the ESI. Although feasible, using standard written case scenarios to determine ESI

triage scoring effectiveness may not be the optimum means to rate nurses‘ triage skills.

Aeimchanbanjong and Pandee (2017) conducted a study "Validation of different

pediatric triage systems in the emergency department" This study aimed to determine the

best triage system in the pediatric emergency department. This was a prospective

observational study., we included 1 041 participants with average age of 4.7±4.2 years, of

which 55% were male and 45% were female. In addition, 32% of the participants had

underlying diseases, and 123 (11.8%) patients were admitted. We found that ESI

illustrated the most appropriate predicting ability for admission with sensitivity of 52%,

specificity of 81%, and AUC 0.78 (95%CI 0.74–0.81). They concluded that: RTS

illustrated almost perfect inter-rater reliability. Meanwhile, ESI and CTAS illustrated good

inter-rater reliability. Finally, ESI illustrated the appropriate validity for triage system.

Wolf et al., (2018) conducted a study was " Triaging the Emergency Department, Not the

Patient: United States Emergency Nurses‘ Experience of the Triage Process" The purpose

of this study was to explore emergency nurses‘ understanding of—and experience with—

27
the triage process, the result of the study was: our participants described processes that

were unit- and/or nurse-dependent and were manipulations of the triage system to ―fix‖

problems in ED flow, rather than a standard application of a triage system. . Contribution

to Emergency Nursing Practice was: This study explored the experience and understanding

of triage as a nursing process in emergency setting, A better understanding of how

environmental constraints affect the decision-making capabilities of emergency nurses

finally, Clear metrics and assessment mechanisms for triage competencies.

Hardy and Calleja (2018) conducted a study was " Triage education in rural remote

settings: A scoping review" The purpose of this review was; to discover how effective

education support programs were in developing clinical decision-making skills for

graduates at triage; and to determine what is known about triage education support

programs for graduate or novice registered nurses undertaking triage in rural and remote

settings. They concluded that: This review demonstrates significant gaps in the literature

reporting on this topic area, particularly in the rural context. Common recommendations

include standardized triage education strategies, and strategies that account for differences

in resourcing levels. Further research is required to attempt to link education strategies in

rural contexts to acceptable triage outcomes like triage accuracy.

Firouzkouhi et al., (2017) conducted a study was" Experiences of civilian nurses in triage

during the Iran-Iraq War: An oral history. These studies aimed to investigate the triage

experiences of civilian nurses during the Iran-Iraq War. The result was: Four themes were

extracted from the data, which were the development of triage, challenging environment to

perform triage, development of mobile triage teams, and challenges of triage chemical

victims for nurses. They concluded that: Triage is an important skill for nurses to manage

critical situations such as disasters and wars. Nurses have to be competent in performing

triage. Involvement in critical situations helps the nurses learn and gain more experience

on how to manage unexpected events.

28
Natareno (2018). Conducted a study was"Disaster Knowledge and Awareness of Nurses

Related to Triage in Mass Casualty Incidents" summary as: American life, as we know it,

is changing. Disasters are increasing in frequency. Over the past decade, more than two

million people has lost their lives. This quality improvement project evaluated the

effectiveness of an evidence-based disaster awareness program specifically designed for

nurses who work in the emergency department. This quality improvement project used

David Kolb‘s Experiential Learning and the Kellogg Foundation‘s Logic as an

organizational framework. goal, the educational intervention consisted of a variety of

educational opportunities, including a self- study packet, an interactive poster, and group

discussions.

Mahmoudi et al., (2017) conducted a study" The Effect of Nurses‘ Triage Training Based

on Stabilization Model on the Patient‘s Waiting Time in Emergency Department". This

study aimed to evaluate the effect of nurses‘ triage education based on stabilization model

on the patient‘s waiting time in the emergency department of selected hospital. the result

was: There was a significant difference between the mean waiting time before and after the

intervention. In a way that the mean of first waiting time before the intervention was 15.34

minutes that reduced to 8.42 minutes after the intervention (P<0.0001). Moreover, the

mean of second waiting time before the intervention was 14.58 minutes which decreased to

14.17 minutes after the intervention. However, the difference was not statistically

significant (P=0.82). they concluded that: Nurses‘ triage training based on stabilization

model reduces the patient‘s waiting time in the emergency department and in turn,

accelerates service delivery. Therefore, we emphasize providing triage education to the

emergency nurses.

29
Augustyn et al., (2009) conducted a study " Nurses and doctors' perceptions regarding the

implementation of a triage system in an emergency unit in south Africa ". In this

descriptive, quantitative and exploratory study, 15 nurses and doctors completed

questionnaires. The challenges decreased and the sorting of patients improved after the

implementation of the Cape Triage Score. Other strengths of this system included that the

triage nurse prioritized patients, as opposed to the receptionist or the administrative staff;

and nurses could undertake preliminary investigations without waiting for doctors‘ orders

to do so. The weaknesses of the implemented Cape Triage Score included that it was not

fully functional 100% of the time, and that it was diffi cult to maintain during peak

admission periods due to a shortage of nurses. The recommendations included that

management should be convinced of the system‘s benefits; nurses should perform the

triage function on a rotation basis; more nurses should be available during peak periods;

and that the administrative and reception staff should also be orientated about the triage

system.

In USA Heather et al., (2016) conducted a study " An Emergency Triage Assessment and

Treatment (ETAT)-based triage process in pediatric emergency department of a

Guatemalan public hospital" that was a quality improvement comparison with a

before/after design. Uptake was measured by percentage of patients with an assigned triage

category, they concluded that: Pediatric-specific triage algorithms can be implemented and

sustained in resource-limited settings. Significant decreases in admission rates (both

overall and for the PICU) and trends towards decreased LOS and mortality rates of

critically ill children suggest that ETAT-based triage systems have the potential to greatly

improve patient care in USA.

30
In UK Seiger et al., (2014) conducted a study was " Improving the Manchester Triage

System for Pediatric Emergency Care: An International Multicenter Study was aimed to

examines the performance of the Manchester Triage System (MTS) after changing

discriminators, and with the addition use of abnormal vital sign in patients presenting to

pediatric emergency departments. At pediatric EDs of two hospitals in The Netherlands

(2006–2009), one in Portugal (November–December 2010), and one in UK (June–

November 2010), They concluded that: MTS 2 did not improve the performance of nurses

at the MTS and with the MTS1 nurses performed slightly better than the original MTS.

The use of vital signs (MTS 2) did not improve the performance of nurses at the MTS.

In Canada Hategekimana et al., (2016) conducted a study "Correlates of Performance of

Healthcare Workers in Emergency, Triage, Assessment and Treatment plus Admission

Care (ETAT+) Course in Rwanda , the aim of the study to evaluate the impact of the

ETAT+ course on HCWs knowledge and practical skills, and to identify factors associated

with greater improvement in knowledge and skills. They concluded that the study shows a

positive impact of ETAT+ course on improving participants‘ knowledge and skills related

to managing emergency pediatric and neonatal care conditions.

In Somaliland, Sunyoto, et al., (2014) conducted a cross – sectional study that " Providing

emergency care and assessing a patient triage system in a referral hospital in Somaliland",

This study aimed to describe the feasibility of managing an ED, including implementation

of the SATS, in a district referral hospital in Somaliland during its first year of service.

They concluded that: This is the first study assessing the implementation of SATS in a

post-conflict and resource limited African setting showing that most indicators met the

expected standards. In particular, specific attention is needed to improve the relatively low

rate of true emergency cases, delays in patient presentation and in timely provision of care

within the ED.

31
In South Africa, Jacques et al., (2017) conducted retrospective study that (The modified

south African triage scale system for mortality prediction in resource constrained

emergency surgical centers), The aim of the study was to verify if data from the south

Africa triage system (SATS) combined with other easily available patient characteristics

can facilitate the identification of patients at high risk of mortality. Such patients could then

receive more focused supportive care during their inpatient stay. They concluded that

SATS category, patient age, and reason for admission can be used to predict in-hospital

mortality. This predictive model had good discriminative ability to identify ED patients at

a high risk of death and performed better than the SATS alone.

Ray et al., (2017) conducted a study was (Clinician attitudes toward adoption of pediatric

emergency telemedicine in rural hospitals). They examined attitudes regarding pediatric

emergency telemedicine, including barriers to adoption in rural settings and potential

strategies to overcome these barriers. The Results was: Factors influencing adoption of

pediatric emergency telemedicine were identified and categorized into 3 domains:

contextual factors (such as regional geography, hospital culture, and individual

experience), perceived usefulness of pediatric emergency telemedicine, and perceived ease

of use of pediatric emergency telemedicine. They concluded that: More effective adoption

of pediatric emergency telemedicine among clinicians will require addressing perceived

usefulness and perceived ease of use in the context of local factors. Future studies should

examine the impact of specific identified strategies on adoption of pediatric emergency

telemedicine and patient outcomes in rural settings.

32
Summary

A lot of international studies conducted about the level or evaluation of nurse's knowledge

and perception regarding triage system and the barriers of triage implementation. In Gaza

strip there is no any study about nurses' triage knowledge or perception and

implementation, Also the triage system is unimplemented on Gaza pediatric hospitals, the

MOH take into consideration to assess and solving it's to implement the triage system

barriers at PED.

33
3 Chapter Three
Materials and Methods

This chapter explained the health systems research design and methods which included the

study population and its eligibility criteria, sample size, sampling technique which used,

the method of data collection, data analysis methods.

3.1 Study design

The design of this study is descriptive, analytical, cross-sectional design. The researcher

Chooses to implement this design because it is the best design to describe the nurse's

knowledge and perception. This type of study is useful to gather information on important

health-related aspects of participants‟ knowledge at one a specific point of time. It is quick,

cheap, easy to conduct, and it enables the researcher to meet the study objectives in a short

time (Sedgwick, 2014).

3.2 Setting of the study

The study conducted in pediatric emergency departments in all governmental hospitals in

the Gaza Strip (Bet-Hanon Hospital (BHH), Kamal-Edwan Hospital (KEH), Al-Dora

Hospital (ADH), Al-Rantisi Hospital (ARH), Al-Nasser Pediatric Hospital (ANPH), Al-

Aqsa Hospital (AQH), Nasser Medical Complex (NMC), and European Gaza Hospital

(EGH)); all of these hospitals have 8 departments provide emergency care for children all

over the Gaza Strip.

3.3 Study population

The population of the study consisted of all nurses currently working in the pediatric

emergency departments at governmental hospitals in the Gaza Strip. Their total number is

120 nurses.

34
3.4 Study sampling and sample size
The sample of the study was the same as the population (census sample). In this study, 112

nurses agreed to participate in the study with response rate 93.3%. The study participants

are from all the governmental hospitals that have pediatric emergency departments as

presented below.

Table (‎3.1): Distribution of study participants according to hospital

Hospital name N %
Alnassr pediatric 18 16.0
Kamal Odwan 19 17.0
Al Rantisi 8 7.2
Al Aqsa 15 13.4
Nasser Medical Complex (NMC) 13 11.6
European Gaza Hospital (EGH) 10 8.9
Al Dorra 20 17.9
Bet Hanoon 9 8.0
Total 112 100.0

3.5 Instrument of the Study

Self-administered questionnaire was developed by the researcher to assess knowledge,

Perception and triage implementation challenges of nurses regarding pediatric triage

implementation. Based on conducted research literature; globally and locally. An expert

panel team of researchers consulted to assess clarity and relevance of the newly developed

questionnaire to the objectives of the study in term of content validity. The Questionnaire

consist of four domains, the first domain for socio-demographic data for participants, the

second domain for knowledge domain and their answer (Yes, No), the third and fourth

domain for perception and challenges and their answers were Likert scale (Strongly Agee,

Agree, Neutral, Disagree, Strongly Disagree).

35
3.6 Reliability and Validity

3.6.1 Validity

After constructing the questionnaire, it reviewed by experts, to judge face and content

validity, and to get feedback and comments, the questionnaire evaluated by five arbitrators

to assess the validity of the questionnaire, comments and modifications applied as needed.

The filling of the questionnaires takes the same of recommended time.

3.6.2 Reliability

The reliability of the questionnaire tested immediately after data cleaning and pilot study

and statistically by Cronbach Alpha test with accepted reliability coefficient not less than

0.7. The reliability improved by modification of the instrument and its implementation,

design of self-administer questionnaire manual and data collection collected by the

researcher himself and other data collectors.

Table (‎3.2): Reliabilities estimates for domains after pilot study

Domains Items Cronbach Alpha

Knowledge 11 items 0.83
Perception 11 items 0.75
Challenges 13 items 0.65

The reliability test was calculated for three domains (Knowledge, Perception, and

Challenges) after finished the collection of data from all participants and analyzed by

SPSS, it showed that Cronbach‘s Alpha equal 0.78 for the total questions.

3.7 Data Collection

The researcher ask the participant to fill full self-administered questionnaire; data was

collected during unit visiting in different times during shifts (day, evening, night) in the

period of study from ―Dec 2018. – Oct. 2019‖.

36
3.8 Eligibility Criteria

3.8.1 Inclusion Criteria:

Nurses currently worked at pediatric emergency department at governmental hospitals

3.8.2 Exclusion Criteria:

1- Students were presented in emergency department during clinical training.

2- Participants who refuse to participate in the study.

3- Volunteer‘s nurses worked at pediatric emergency departments for more than 6 months.

3.9 Pilot Study

A pilot study conducted for 10 nurses, they filled the questionnaire before starting the

whole data collection as a pre-test to point out weaknesses in wording, predicted response

rate, determined the real time needed to fill the questionnaire and identified areas of

vagueness and to test the reliability and suitability of the questionnaire. the questionnaire

that used for piloting don‘t added to the sample of the study after modification occurs.

3.10 Statistical management and procedures

After checking and reviewing all filled questionnaires on the same way, data were entered

in the computer using SPSS (Statistical Package for Social Science) software version 23

for data coding, entry, and analysis. After finishing the data entry process, check codes

were used to avoid double entries. Pretesting of the tool were done to eliminate

inconsistencies and made the questions relate to the local setting. Data cleaning were done

to account for missing value in a bid to ensure integrity and reliability. Frequencies and

cross tabs were used to do the data analysis. First, data cleaning was done to ensure that all

37
data entered accurately and in appropriate way. Data cleaning were conducted through

selecting and checking out of a random number of the filled questionnaires, and also

through operating frequencies and descriptive statistical test as Chi square. The level of

significance was set at a P value of less than 0.05, confidence interval (CI) at 95%.

3.11 Ethical and administrative considerations

The researcher committed to all ethical consideration required to conduct a research.

Ethical approval taken from Helsinki Committee in Gaza Governorates, MOH, in addition

to approval from College of Health Professional at Al-Quds University was obtained by

formal application. Every participant in the study receives a complete explanation of the

research purposes, they informed about the optional participation in the study and

confidentiality was given and maintained. The protection for the rights of the participants

was a priority in this study and all the ethical consideration observed and respected for

people and human rights and respect for truth.

3.12 Period of the study

The study was carried out during the period from December 2018 to December 2019.

38
4 Chapter Four
Results and Discussion

This chapter presents the findings of statistical analysis of data. Description of participants‘

characteristics is illustrated. Results of different variables were identified, and the

differences between selected variables were explored and discussed in relation to literature

review and previous studies.

4.1 Socio-demographic characteristics of study participants

Table (‎4.1): Distribution of study participants by work conditions (n= 112)

Variable N %
Job title
Practical nurse 37 33.0
Staff nurse 69 61.6
Nurse manager 6 5.4
Total 112 100.0
Working shifts
Day shift 30 26.8
Evening-night shift 35 31.2
Day & evening night shift 47 42.0
Total 112 100.0
Have you received training about triage system?
Yes 37 33.0
No 75 67.0
Total 112 100.0

As shown in table (4.1), 69 (61.6%) of study participants were staff nurses, 37 (33%) were

practical nurses and 6 (5.4%) were nurse managers. Also, 47 (42%) of study participants

work day & evening shift and 35 (31.2%) work evening-night shift. 33% of the nurses who

participate on this study was attended to triage training course supervised by WHO, On the

39
other hand 67.0% of the nurses participate on this study wasn‘t attended on triage training

course before. By compare with study (Afaya et al., 2017) Out of the sixty-five (65)

participants, 37(56.9%) were males. Majority of the nurses 70.8% were of 21-30 years of

age. In relation to the specialty areas of nurses, majority (87.7%) were registered general

nurses with only 9.2% were emergency nurses. In relation to participants‟ education level,

majority of the nurses 33(50.8%) were diploma degree holders.

Figure (‎4.1): Distribution of study participants according to gender.

Figure (4.1) showed that 76.8% of study participants were male nurses, and 23.2% were
females.

Figure (‎4.2): Distribution of study participants according to marital status

The participant was mainly married with 67.3%, the single was only 32.7% of the study

sample.

40
 Place of Residence
40
35
30
25
20
30.4% 29.5% 15
20.5%
10
14.3%
5.4%

Rafah Khan Younis Middle Gaza North

Figure (‎4.3): Distribution of study participants according to place of residence.

According to the place of residence 5.4% of the participant was from Rafah,14.3% of the

participant was from khan Younis, 20.5% of the participant was from the middle area, also

30.4% of the participant was from Gaza and 29.5% of the participant was from the north.

QUALIFICATION
Master 2%
Diploma
32%

Bachelor
66%

Figure (‎4.4): Distribution of study participants according to qualification

According to the qualification the nurses participate on this study was mainly bachelor

degree in nursing with percent 66%, Diplom with nurses 32% and master nurses was 2%.

41
 Figure (‎4.5): Distribution of study participants according to age

According to the age of the study sample most of them were from 28 – 38 years.

Experience(yrs.)

41.40%
31.30%
27.70%

More than 9 yrs.. From 3 to 9 yrs.. Less than 3 yrs. .

Figure (‎4.6): Distribution of study participants according to years of experience

Figure 4.6 demonstrate that most of the participant have an experience less than 3 year

(41.4%) and then more than 9 year with percent (31.3%).

42
4.2 Knowledge about triage system
Table (‎4.2): Knowledge about triage system among study participants (n= 112)

Agree Disagree Mean Ran

No. Item Mean SD
n (%) n (%) (%) k
I received theoretical and
1 practical lectures on the system 43(38.4) 69(61.6) 1.38 0.488 69.0 11
of work of the triage in the ED
I have enough knowledge about
2 how the triage system works in 61(54.5) 51(45.5) 54.1 0.500 77.0 6
the ED
I have the ability to clearly
3 explain how the triage system 56(50.0) 56(50.0) 50.1 0.502 75.0 7
works for other colleagues
I can perform nursing tasks in
the medical triage hall based on
4 67(59.8) 45(40.0) 59.1 0.492 79.5 3
a thorough knowledge of the
triage system
I can distinguish between the
5 Triage system cards and the 68(60.7) 44(39.3) 60.1 0.490 80.0 2
time value and priority of each
The Triage system is based on
sorting cases with different
6 74(66.1) 38(33.9) 66.1 0.475 83.0 1
color cards globally agreed
upon
I have full knowledge of the
7 possible waiting time for each 44(39.3) 68(60.7) 39.1 0.490 69.5 10
color individually
The patient with the red card
8 can wait up to an hour for 67(59.8) 45(40.2) 59.1 0.492 79.5 3
medical care
A yellow card patient can wait
9 up to three hours for medical 64(57.1) 48(42.9) 57.1 0.497 78.5 5
care
The patient with the black card
10 does not require medical care or 50(44.6) 62(55.4) 44.1 0.499 72.0 8
intervention
The patient with the green card
11 needs urgent and immediate 50(44.6) 62(55.4) 44.1 0.499 72.0 8
medical intervention
Overall 1.52 0.190 76.0

Table (4.2) shows the highest score obtained in knowing that the triage system is based on

sorting cases with different color cards globally agreed upon with mean percent 83.0%,

followed by ability to distinguish between the triage system cards and the time value and

priority of each with mean percent 80.0%. The lowest score was in receiving theoretical

43
and practical lectures on the system of work of the triage in the ED with mean percent

69.0%, followed by having full knowledge of the possible waiting time for each color

individually with mean percent 69.5%. The average of overall knowledge about triage

system was 76.0%, which indicated above moderate knowledge. This result was higher

than the results of Afaya et al. (2017) which revealed that 62.6% of the respondents were

knowledgeable about triage system. Inconsistent result obtained in a study carried out by

Allen et al. (2015) which showed that 69% of study participants had poor knowledge about

triage system. In addition, the results of Fathoni (2013) found low level of knowledge

about triage system among nurses working in the emergency centers. Moreover, the

results obtained by Robert et al. (2014) found that 33% of the respondents were not

knowledgeable about triage, 13% reported that although they had attended workshops,

there had been a lack of information on how to triage patients, 52% of the respondents

were not able to allocate the patient to the appropriate triage category. Furthermore, 58%

had no knowledge on waiting time limits for the triaged categories. Another study carried

out by Bereket et al. (2019) found that 51.5% of the study participants had low triage

knowledge.

Moreover, a study conducted by Aghababaeian et al. (2017) found that the mean

knowledge about triage among the study participants was average.

In the researcher opinion, adequate knowledge and high skills are needed to practice triage

appropriately for the triage of patients. Therefore, there is a need for in-service training and

education programs on a regular basis to maintain professional development and updated

clinical skills.

44
4.3 Perception about triage system
Table (‎4.3): Perception about triage system among study participants (n= 112)

Strongly disagree

Mean weight (%)

Strongly agree
Disagree

Neutral

Agree

Mean

Rank
SD
No Item

The Triage system affects the

1 quality of healthcare in EDs 0 1.8 1.8 38.4 58.0 4.52 0.629 90.4 1
significantly
Triage plays a major role in
2 reaching patients and their families 0.9 5.4 17.0 46.4 30.4 4.00 0.880 80.0 9
The basis of the Triage system is
3 based on the optimal utilization of 0 3.6 13.4 50.9 32.1 4.11 0.768 82.2 8
capabilities and capabilities
The implementation of the Triage
4 system needs huge supplies and 2.7 33.0 10.7 33.0 20.5 3.35 1.214 67.0 10
efforts
Triage system is one of the
5 foundations of patient safety in ED 0 3.6 8.9 42.9 44.6 4.28 0.776 85.6 6
The Triage system is an effective
6 way of dealing with congestion in 0 1.8 5.4 46.4 46.4 4.37 0.672 87.4 3
the ED
I believe in the importance of the
7 role of the nurse in the application 0.9 0.9 4.5 49.1 44.6 4.35 0.695 87.0 5
of the Triage system in the ED
Nursing and medical staff can
control the overcrowding of cases
8 in the emergency department 7.1 41.1 19.6 18.8 13.4 2.90 1.192 58.0 11
without activating the triage system
I believe in the key role of the
Triage system in providing
9 emergency health care in the 0 5.4 13.4 42.9 38.4 4.14 0.847 82.8 7
pediatric ED as a priority
I would like to participate in
courses, conferences and scientific
10 activities that enhance the 0 2.7 7.1 36.6 53.6 4.41 0.741 88.2 2
importance of applying the system
of triage in ED
We are convinced of the need to
activate the Triage system in the
11 management of cases at ED 0 3.6 8.9 34.8 52.7 4.36 0.794 87.2 4
overcrowding
Overall 4.07 0.396 81.4

Table (4.3) showed that the highest score obtained in perceiving that the triage system

affects the quality of healthcare in EDs significantly with mean percent 90.4%, followed

by ―I would like to participate in courses, conferences and scientific activities that enhance

the importance of applying the system of triage in ED with mean percent 88.2%. The

45
lowest score obtained in ―nursing and medical staff can control the overcrowding of cases

in the emergency department without activating the triage system: with mean percent 58%,

followed by ―the implementation of the Triage system needs huge supplies and efforts‖

with mean percent 67%. The average overall perception was 81.4%, which indicated high

perception about triage system. This result was nearly consistent with Akinaga et al. (2017)

which showed that most students were likely to answer the triage questions largely based

on their perception of visual information (such as video images) rather than on triage

criteria. In addition, the study of Afaya, et al. (2017) revealed that the majority of nurses

(96%) in the ED of the various hospitals had a very good perception about the importance

of triage to the patient, care provider and the country at large. Another study carried out by

Bereket, et al. (2019) found that 76.2% of participants perceived their overall triage skill to

be at good level. A study carried out in Egypt found that the median attitude score towards

emergency cases was 82.3% for physicians and 81.9% for nurses. Most physicians (94.1%)

and nurses (85.0%) had practiced emergency care in the primary health care. More

physicians as compared to nurses (58.8% versus 50.7%) reported greatest need for

continuing medical education in the management of pediatric emergencies. More than half

of physicians endorsed hospital training (58.8%) while 48.4% endorsed practical training

in PHC settings (Mohey, 2017).

The researcher believes that appositive perception about triage is an important factor that

will enhance the triage system, and motivate the triage staff to categorize the patients

correctly according to their condition and seriousness of their illness when they present to

the ED.

46
4.4 Challenges to triage implementation

Table (‎4.4): Challenges to triage system (n= 112)

Strongly disagree

Mean weight (%)

Strongly agree
Disagree

Neutral

Agree

Mean

Rank
SD
No Item

I think that there are major

challenges and obstacles that
1 will face the implementation of 1.8 31.3 9.8 33.9 23.2 3.45 1.207 69.0 3
the triage system at pediatric
emergency department
The working environment is
suitable and suitable for the
2 possibility of the triage system
5.4 42.0 18.8 28.6 5.4 2.86 1.061 57.2 7
implementation
The decision-makers motivated
3 to implement the triage system
3.6 29.5 17.0 40.2 9.8 3.23 1.090 64.6 5
The nursing staff currently in
4 my department is sufficient to 16.1 48.2 15.2 13.4 7.1 2.47 1.130 49.4 8
implement the triage system
The nursing staff has the real
5 motivation to apply the triage 5.4 14.3 9.8 35.7 34.8 3.80 1.214 76.0 2
system
Cases overcrowding is one of
the obstacles to the
6 implementation of the triage
5.4 29.5 17.9 26.8 20.5 3.27 1.239 65.4 4
system
I think the public has enough
7 idea about how the triage 19.6 54.5 15.2 6.3 4.5 2.21 0.981 44.2
system works
There is a really desire among
8 the public to implement the 14.3 55.4 17.0 10.7 2.7 2.32 0.941 46.4 9
triage system
The department has material
resources that allow the triage
9 system to be easily
17.0 58.9 8.0 16.1 0 2.23 0.920 44.6 11
implemented
Human security controls are
available that can control any
10 mess in the triage hall and 19.6 58.0 8.0 10.7 3.6 2.20 0.996 44.0 13
contribute to the time
limitations of the triage system
Triage room contain
adjustment banners that guide
11 people and help to understand
23.2 52.7 7.1 10.7 6.3 2.24 1.116 44.8 10
triage working method
There is a sufficient time for
12 nurses to implement triage at 14.3 33.9 14.3 15.2 22.3 2.97 1.404 59.4 6
pediatric emergency
Work load at pediatric
13 emergency impedes triage 5.4 15.2 6.3 33.9 39.3 3.86 1.241 77.2 1
implementation
Overall 2.85 0.388 57.0

47
Table (4.4) shows that the highest score obtained in the challenge that work load at

pediatric emergency impedes triage implementation with mean percent 77.2%, followed by

the nursing staff has the real motivation to apply the triage system with mean percent 76%.

The lowest score was in ―human security controls are available that can control any mess

in the triage hall and contribute to the time limitations of the triage system‖ with mean

percent 44%, followed by ―I think the public has enough idea about how the triage system

works: with mean percent 44.2%. The average overall challenges were 57%, which

indicated moderate level of challenges to implement triage system in pediatric emergency

departments. The study of Augustyn (2009) showed that the most prominent challenges

prior to the implementation of the Cape Triage Score were the patients‘ complaints about

their long waiting times (86.6%) and the time taken for doctors to see patients (80.0%). In

addition, 53.3% (n=8) of the respondents indicated that receptionists and administrative

staff incorrectly prioritized patients. Several challenges influence the implementation of

triage system in EDs. The challenges include availability of written clinical practice

guidelines for providing emergency services, guidelines for pediatric emergency triage,

assessment or treatment and referral guidelines, and lack of some essential equipment and

drugs (Mohey, 2017).

In the researcher opinion, the triage system is a big challenge in Gaza Strip. It is a new

concept that can be implementing in governmental hospitals with support from the

International Committee of Red Cross – Gaza office. To run triage properly, the structure

of ED should be arranged well with availability of security personnel to avoid overcrowd

by escorts. In addition, the staff (including nurses and doctors) who are working in EDs

should be trained on triage system, performing good assessment, and categorize patients

accurately according to the severity of their illness.

48
4.4 Relationship between knowledge, perception, and challenges
Table (‎4.5): Relationship between knowledge, perception, and challenges to triage implementation

Variable Knowledge Perception Challenges

Correlation 1
Knowledge
P value
Correlation 0.045 1
Perception
P value 0.639
Correlation 0.096 -0.201-* 1
Challenges
P value 0.315 0.034

Pearson correlation test *Correlation is significant at the 0.05 level (2-tailed).

Table (4.5) showed that there was statistically significant negative relationship between

perception about triage system and challenges to implement triage system (r= -0.201, P=

0.034), which means that as triage system challenges decrease, perception will increase. In

addition, there were statistically no significant relationship between knowledge and

perception (P= 0.639), and knowledge and challenges (P= 0.315).

In the researcher opinion, having positive perception about triage is an essential factor for

the success of any triage system. If the nurse or physician have a positive perception, that

will decrease the barriers and challenges that hinder the implementation of the triage

system. In addition, employing adequate qualified staff is another challenge that will make

the difference for the appropriate implementation of triage system.

49
4.5 Relationship between knowledge, perception, challenges, and
sociodemographic characteristics
Table (‎4.6): Relationship between knowledge, perception, challenges and gender (n= 112)

Variable Gender N Mean SD T value P value

Male 86 1.524 0.194

Knowledge 0.159 0.874
Female 26 1.517 0.181

Male 86 4.087 0.385

Perception 0.553 0.581
Female 26 4.038 0.438

Male 86 2.862 0.401

Challenges 0.185 0.854
Female 26 2.846 0.348

Independent sample (t) test

Table (4.6) showed that there were statistically no significant differences in knowledge

about triage system (P= 0.874), perception about triage system (P= 0581), and challenges

to implementing triage system (P= 0.854) related to gender.

Healthcare inefficiency and error can result from implicit social factors associated with the

health provider‘s characteristics themselves. The results obtained by Vigil et al., (2017)

found that assessment of nurse's knowledge did not differ by nurse‘s gender; however

higher levels were associated with higher priority emergency severity index.

This result is logic as nurses who are working in ED, regardless of their gender have

similar knowledge and perception about triage system as they are working in the same

place with similar environment and policies.

50
Table (‎4.7): Relationship between knowledge, perception, challenges and age (n= 112)

Variable n Mean SD F P value

Less than 28 years 39 1.575 0.159

28 – 38 years 49 1.462 0.194
Knowledge 4.766 0.010*
39 and more 24 1.560 0.201
Total 112 1.522 0.190
Less than 28 years 39 4.081 0.393
28 – 38 years 49 4.115 0.382
Perception 0.821 0.443
39 and more 24 3.988 0.431
Total 112 4.076 0.396
Less than 28 years 39 2.948 0.418
28 – 38 years 49 2.799 0.385
Challenges 1.700 0.187
39 and more 24 2.833 0.324
Total 112 2.858 0.388

*Significant at 0.05 One-way ANOVA test

Table (4.7) showed that there were statistically significant differences at 0.05 in knowledge

about triage system related to age (F= 4.766, P= 0.010). Post hoc LSD indicated that

participants from the age group 28 – 38 years had the lowest level of knowledge compared

to their counter parts from other age groups. In addition, the results showed that there were

statistically no significant differences in perception and challenges to implementing triage

system related to age of participants.

When running ANOVA test and get a significant result, that means at least one of the

groups tested differs from the other groups. However, the ANOVA test will not tell

which group differs. In order to determine the direction of the differences, we use post hoc

multi-comparison test. The least significant difference (LSD) calculates the smallest

significant differences between two means as if a test had been run on those two means.

51
Table (‎4.8): Relationship between knowledge, perception, challenges and marital status (n= 112)

Marital
Variable n Mean SD T value P value
status

Single 32 1.571 0.177

Knowledge 1.709 0.090
Married 80 1.503 0.193

Single 32 4.028 0.398

Perception -0.807 0.421
Married 80 4.095 0.396

Single 32 2.983 0.383

Challenges 2.186 0.031*
Married 80 2.808 0.380

*Significant at 0.05 Independent sample (t) test

Table (4.8) showed that there were statistically significant differences at 0.05 in challenges

to implement triage system related to marital status (P= 0.031), which means that

participants who are single reported higher challenges to implement triage system

compared to married participants. In addition, there were statistically no significant

differences in knowledge (P= 0.090) and perception (P= 0.421) toward triage system

related to marital status.

In the researcher opinion, nurses who are working in ED, either single or married, are

working in the same place, with the same conditions, same work environment, and same

policies, so, they will have similar knowledge and perception about triage. Other factors

may cause differences in knowledge and perception such as work experience, qualification,

and previous training on triage.

52
Table (‎4.9): Relationship between knowledge, perception, challenges and place of residency
(n= 112)

Variable n Mean SD F P value

North 33 1.427 0.207

Gaza 34 1.502 0.173
Middle 23 1.581 0.146
Knowledge 5.560 0.000*
Khanyounis 16 1.619 0.176
Rafah 6 1.681 0.076
Total 112 1.522 0.190
North 33 4.140 0.422
Gaza 34 4.128 0.406
Middle 23 3.972 0.378
Perception 2.423 0.053
Khanyounis 16 3.886 0.295
Rafah 6 4.333 0.279
Total 112 4.076 0.396
North 33 2.724 0.324
Gaza 34 2.778 0.378
Middle 23 2.862 0.351
Challenges 5.992 0.000*
Khanyounis 16 3.182 0.373
Rafah 6 3.166 0.387
Total 112 2.858 0.388

*Significant at 0.05 One-way ANOVA test

Table (4.9) showed that there were statistically significant differences in knowledge about

triage system related to place of residency (F= 5.560, P= 0.000). Post hoc LSD indicated

that participants from the North and from Gaza had significant lower knowledge about

triage system compared to participants from Khanyounis and Rafah. The results also

showed that there were statistically significant differences at 0.05 in challenges to

implement triage system related to place of residency (F= 5.992, P= 0.000). Post hoc LSD

indicated that participants from Khanyounis and Rafah reported higher challenges to

implement triage system compared to participants from North, Gaza, and middle

governorate. Furthermore, the results did not show significant differences in perception

about triage system related to place of residency.

53
Table (‎4.10): Relationship between knowledge, perception, challenges and qualification (n= 112)

Educational
Variable n Mean SD T value P value
level

Diploma 36 1.462 0.188

Knowledge -2.361 0.020*
Bachelor 76 1.551 0.186

Diploma 36 4.060 0.403

Perception -0.287 0.775
Bachelor 76 4.083 0.396

Diploma 36 2.841 0.488

Challenges -0.311 0.756
Bachelor 76 2.866 0.333

*Significant at 0.05 Independent sample (t) test

Table (4.10) showed that there were statistically significant differences at 0.05 in

knowledge about triage system related to qualification (P= 0.020), and participants who

have bachelor degree expressed higher knowledge compared to those who have diploma

certificate. In general, the results showed statistically no significant differences in

perception and challenges to implement triage related to qualification of participants.

Inconsistent results obtained by Küçükoğlu et al. (2017) who found statistically significant

differences in triage practices related to level of education. They also found that 72.7% of

the nurses did not consider themselves qualified to perform triage, and 68.2% believed that

triage was among the duties of emergency care nurses. It was also determined that the

physical environment of the emergency department, the ability of personnel to triage and

the absence of specialist physicians and nurses were factors affecting triage practice.

Another study carried out by Bereket, et al. (2019) found that educational level of study

participant is a significant factor associated with triage knowledge and skill.

54
Table (‎4.11): Relationship between knowledge, perception, challenges and job title (n= 112)

Variable n Mean SD F P value

Practical nurse 37 1.476 0.195

Staff nurse 69 1.528 0.182
Knowledge 5.497 0.005*
Nurse manager 6 1.742 0.068
Total 112 1.522 0.190
Practical nurse 37 4.073 0.395
Staff nurse 69 4.071 0.402
Perception 0.113 0.894
Nurse manager 6 4.151 0.392
Total 112 4.076 0.396
Practical nurse 37 2.835 0.478
Staff nurse 69 2.871 0.340
Challenges 0.105 0.900
Nurse manager 6 2.846 0.337
Total 112 2.858 0.388

*Significant at 0.05 One-way ANOVA

Table (4.11) showed that there were statistically significant differences at 0.05 in

knowledge about triage system related to job title (F= 5.497, P= 0.005). Post hoc LSD

indicated that nurse managers have significant higher knowledge compared to participants

with diploma and bachelor degree. In addition, the results showed no statistically

significant differences in perception and challenges to implement triage system.

55
Table (‎4.12): Relationship between knowledge, perception, challenges and experience in pediatric
ED (n= 112)

Variable N Mean SD F P value

Less than 3 years 46 1.523 0.184

3 – 9 years 31 1.480 0.188
Knowledge 1.366 0.259
More than 9 years 35 1.558 0.199
Total 112 1.522 0.190
Less than 3 years 46 4.055 0.383
3 – 9 years 31 4.099 0.424
Perception 0.121 0.886
More than 9 years 35 4.083 0.398
Total 112 4.076 0.396
Less than 3 years 46 2.899 0.372
3 – 9 years 31 2.858 0.345
Challenges 0.595 0.554
More than 9 years 35 2.804 0.443
Total 112 2.858 0.388

One-way ANOVA

Table (4.12) showed that there were statistically no significant differences in knowledge

about triage system (P= 0.259), perception about triage system (P= 0.886), and challenges

to implement triage system (P= 0.554) related to years of experience in pediatric ED.

This result was inconsistent with the results of Afaya et al. (2017) which indicated that

nurses who worked for a year or less scored below average knowledge about triage.

Moreover, nurses who worked for two years had scores slightly above average, and nurses

who had three years and four or more years working experience had higher level of

knowledge (74% and 80% respectively). In addition, Fathoni (2013) found that working

experience was correlated with triage skills and knowledge particularly for those who

continued working at ED for more than five years, and those nurses with emergency

experience had more abilities in triage skill than nurses with less years of working

56
experience. Another study carried out by Bereket, et al. (2019) found that working

experience of study participants and triage experience were factors associated with triage

knowledge and skills.

Table (‎4.13): Relationship between knowledge, perception, challenges and work shifts (n= 112)

Variable n Mean SD F P value

Day shift only 30 1.578 0.184

Evening-night 35 1.470 0.196
Knowledge 2.713 0.071
Day, evening & night 47 1.526 0.183
Total 112 1.522 0.190
Day shift only 30 4.021 0.428
Evening-night 35 4.090 0.354
Perception 0.397 0.673
Day, evening & night 47 4.100 0.409
Total 112 4.076 0.396
Day shift only 30 2.848 0.399
Evening-night 35 2.852 0.398
Challenges 0.030 0.970
Day, evening & night 47 2.869 0.381
Total 112 2.858 0.388

One way ANOVA

Table (4.13) showed that there were no statistical significant differences in knowledge

about triage system (P= 0.071), perception about triage system (P= 0.673), and challenges

to implement triage system (P= 0.97) related to working shifts.

In the researcher opinion, nurses who are working in ED usually working in rotating shifts

of morning, evening, and night shifts, therefore, they should have similar knowledge and

perceptions because they are the same nurses who are working in different shifts. It is

obvious that the nurse who is working morning shift this week and working night shift next

week will not change his knowledge and perception about Triage. Therefore, this result

was logic as no significant differences in knowledge and perception related to working

shift at ED.

57
Table (‎4.14): Relationship between knowledge, perception, challenges and hospital

(n= 112)

Variable N Mean SD F P value

Al Nassr Ped. 18 1.494 0.207

Kamal Odwan 19 1.449 0.213
Al Rantisi 8 1.465 0.156
Al Aqsa 15 1.636 0.128
Knowledge NMC 13 1.587 0.184 3.464 0.002*
EGH 10 1.654 0.127
Al Dorra 20 1.513 0.159
Bet Hanoon 9 1.373 0.189
Total 112 1.522 0.190
Al Nassr Ped. 18 3.888 0.416
Kamal Odwan 19 4.043 0.374
Al Rantisi 8 4.397 0.572
Al Aqsa 15 4.012 0.312
Perception NMC 13 3.909 0.287 2.725 0.012*
EGH 10 4.072 0.451
Al Dorra 20 4.268 0.308
Bet Hanoon 9 4.161 0.351
Total 112 4.076 0.396
Al Nassr Ped. 18 2.948 0.379
Kamal Odwan 19 2.696 0.300
Al Rantisi 8 2.721 0.232
Al Aqsa 15 2.912 0.364
3.351 0.003*
Challenges NMC 13 3.171 0.348
EGH 10 3.038 0.421
Al Dorra 20 2.688 0.458
Bet Hanoon 9 2.777 0.186
Total 112 2.858 0.388

*Significant at 0.05 One way ANOVA

58
Table (4.14) showed that there were statistically significant differences at 0.05 in

knowledge about triage system related to hospital (F= 3.464, P= 0.002). Post hoc LSD

indicated that participants from EGH had significant higher knowledge about triage system

compared to participants from other hospitals. In addition, there were statistically

significant differences in perception related to hospital (P= 0.012). Post hoc LSD indicated

that participants from Al Rantisi hospital had significant higher perception about triage

system compared to participants from other hospitals. Moreover, there were statistically

significant differences in challenges to implement triage (P= 0.003). Post hoc LSD

indicated that participants from NMC reported higher challenges to implement triage

system. This result agreed with a study conducted by Haghigh et al. (2017) which showed

different levels of knowledge about triage among nurses from different areas, and that

51.4% of nurses had low level of knowledge and 44.3% had a moderate level of

knowledge about triage.

Triage system started at EGH three years ago in cooperation between the MoH and the

International Committee of Red Cross. The ED at EGH was reconstructed and designed to

make triage for all the patients who comes to the ED. At the same time, the nurses received

special training about triage system by the Red Cross team, therefore, they expressed

higher knowledge about triage compared to other hospitals.

In addition, triage system started at Nasser hospital last year after opening the new ED.

Several challenges face the nurses who are working in ED at Nasser hospital including

inadequate qualified nurses to work as triage nurse, small area designed as triage area,

inadequate cooperation between nurses and physicians, and unavailability of security

personnel all the time. Extra efforts are needed by hospital administration in order to

overcome these challenges and make the triage system functioning well for the benefits of

patients who seek emergency treatment at Nasser hospital ED.

59
Table (‎4.15): Relationship between knowledge, perception, challenges and previous triage training

Received training
Variable N Mean SD T value P value
about triage
Yes 37 1.624 0.172
Knowledge 4.239 0.000*
No 75 1.472 0.179
Yes 37 4.113 0.354
Perception 0.687 0.494
No 75 4.058 0.416
Yes 37 2.943 0.384
Challenges 1.647 0.102
No 75 2.816 0.385

*Significant at 0.05 independent sample (t) test

Table (4.15) showed that there were statistically significant differences at 0.05 in

knowledge about triage system related to training (P= 0.000), which means that

participants who received training about triage system had significant higher knowledge

compared to their counterparts who did not receive training. In addition, there were

statistically no significant differences in perception and challenges to implement triage

between participants who received training and who did not receive training about triage

system. In this regard, Kelly (2010) reported that specialty education and continuing

training in triage contribute considerably to the correct triage decisions that are essential

for good health outcomes and that continuing training but not experience was found to

influence triage decision-making. Therefore, prior to adopting a triage role, nurses should

have both adequate specialized training and experience in the triage system. Karen

Hammad et al. (2017) conducted a study in China found that 50.8% of participants reported

receiving dedicated triage training, which was provided by their employer (38.6%), an

education organization (30.7%) or at a conference (26.1%). Another study carried out by

Pouraghaei et al. (2015) found that providing training program about triage was effective in

improving the knowledge and practice of employees and decreased error in performance.

Another study conducted by Haghigh et al. (2017) found that 51.4% of study participants

60
had low level of knowledge about triage and 44.3% had a moderate level of knowledge

about triage. Furthermore, Hussein et al. (2019) found that there were highly significant

differences in knowledge and skills after implementing an educational program about

triage system in emergency department. In addition, Abdoos, et al. (2016) found that the

frequency of correct triage by trained group was significantly higher than by the untrained

group (80% vs. 30%). Another study conducted by Hategekimana et al. (2016) evaluated

the impact of a training course on knowledge and practical skills. The results showed a

positive impact of the training course on improving participants‘ knowledge and skills

related to managing emergency pediatric and neonatal care conditions.

In the researcher opinion, training is important for nurses to gain knowledge and

experience and keep updated with new development in the nursing field. Triage is a new

system started gradually in EDs at governmental hospitals in GS, so, it is essential to give

the nurses adequate knowledge and skills before working as a triage nurse, so they can

perform their tasks properly and with quality.

61
5 Chapter Five
Conclusion and Recommendations

5.1 Conclusion
The study results revealed that the socio-demographic data weren‘t determinant factors

affecting nurse‘s knowledge, perception, and triage challenges regarding pediatric triage

implementation. The level of knowledge, perception for nurses regarding triage

implementation are corresponding with different studies about triage. The study findings

revealed that nurse's knowledge level about triage in the EDs of various pediatric

government hospitals in Gaza strip were average score (76%). As nurse's knowledge about

triage is a key tool in triage decision making, there is the need to improve on nurse's

knowledge level and skills in triaging at the PED, To improve the knowledge level,

workshops/in-service training should be carried out, followed by continuous professional

development on a regular basis for nurses in the PEDs. Nurses in the PEDs of the various

hospitals should be encouraged to undergo training in emergency, critical care and trauma

nursing, as this will go further to enhance their knowledge on triage which will further

improve the quality of care at PEDs

5.2 Recommendations:

1- The findings of this study could serve as guidelines for research prior to the future

implementation of the same or similar triage systems in other emergency units.

2- Nurses can be trained specifically to perform triage functions and should perform

these functions on a rotating basis. Regular in-service education sessions include

theoretical and practical lectures on the system of work of the triage in the

emergency department include knowledge of the possible waiting time for each color

individually

3- The need for additional nurses during peak periods should be investigated, quantified

62
 and addressed in the most cost-effective manner possible. For example, specific

nurses and doctors could be ‗on-call‘ from 16:00 until 24:00 pm, to assist if the

workflow increases beyond the capacity of the available nurses and doctors during

peak hours.

4- Shortage of human security controls can be considered because them effect that can

control any mess in the triage hall and contribute to the time limitations of the Triage

system

5- Regular assessments can be done of the time that patients have to wait before being

attended to in the emergency unit to quantify slandered appropriate waiting time.

6- The financial cost of maintaining a triage system, such as the need for an additional

registered nurse, quantify and weight against aspects of improved patient care, such

as reduced waiting times, increased patient security, reduced morbidity and mortality

figures, and increased levels of staff members‘ job satisfaction.

7- Nurses and doctors can be encouraged to attend training sessions in implementing the

pediatric triage and to visit other hospitals where this system has been implemented.

Staff members could each visit a different center and provide feedback to the entire

group of doctors and nurses working in this unit. Based on the identified strengths

and weaknesses of the visited centers, best practice guidelines for this unit should be

compiled and tested.

8- Nurses performing triage functions can be requested to keep a diary of challenges

encountered and suggestions for addressing these challenges in future. Regular focus

group discussions about nurses‘ triage experiences should be conducted.

9- Receptionists and administrative staff members scan also be orientated about the

triage process. Future studies should conduct two investigations, before and after the

implementation of the PED triage, in a specific unit. This will produce comparative

data and enable the calculation of correlation statistics.

63
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‫‪7‬‬ ‫‪Annexes‬‬
‫‪Annex 1: Questionnaire in Arabic‬‬

‫معرفة وأدراك الممرضين فيما يتعلق بتنفيذ نظام الفرز (الترياج) في أقسام طوارئ األطفال في قطاع غزة‬

‫‪Nurses Knowledge and Perception Regarding the Implementation of Triage System in‬‬
‫‪Pediatric Emergency Department at Gaza Strip‬‬

‫اإلخوة واألخواث األفاضم‪.......‬‬

‫انسالو عهيكى ورحًت هللا وبركاته‪:‬‬

‫ٕزا اىجذش ٍزطيت ىْ‪ٞ‬و دسجخ اىَبجغز‪ٞ‬ش ف‪ ٜ‬رَش‪ٝ‬ط األغفبه ٍِ جبٍؼخ اىقذط – أث٘ د‪ٝ‬ظ مي‪ٞ‬خ اىذساعبد اىؼي‪ٞ‬ب ٕٗزا اىجذش ٍَ٘ه‬
‫رار‪ٞ‬ب ٍِ اىجبدش د‪ٞ‬ش رٖذف ٕزٓ اىذساعخ ئى‪ ٚ‬رق‪ٍ ٌٞٞ‬ؼشفخ ٗئدساك اىََشظ‪ ِٞ‬ف‪َٞ‬ب ‪ٝ‬زؼيق ثزطج‪ٞ‬ق ّظبً اىفشص اىصذ‪ ٜ‬ف‪ ٜ‬أقغبً‬
‫غ٘اسئ األغفبه ف‪ ٜ‬قطبع غضح‪.‬‬

‫ىزا ّشج٘ ٍْنٌ اىزنشً ثبإلجبثخ ػِ جَ‪ٞ‬غ أعئيخ االعزجبّخ‪ ،‬فشأ‪ٝ‬نٌ ‪َٝ‬ضو إَٔ‪ٞ‬خ مج‪ٞ‬شح ثبىْغجخ ىٖزٓ اىذساعخ ػيَب ثأُ ئجبثزنٌ عزغزخذً‬
‫ألغشاض اىجذش اىؼيَ‪ ٜ‬فقػ ٍغ ظَبُ اىغش‪ٝ‬خ اىزبٍخ‪.‬‬

‫اى٘قذ اىز‪ ٛ‬رغزغشقٔ رؼجئخ االعزجبّخ ال ‪ٝ‬زجبٗص ‪ 15‬دق‪ٞ‬قخ‪ٗ ،‬ف‪ ٜ‬دبه االعزفغبس ػِ أ‪ ٛ‬أعئيخ ‪ٝ‬شج‪ ٚ‬اىز٘اصو ػي‪ ٚ‬ج٘اه سقٌ‬
‫‪0595235481/‬‬

‫وشكرا نحسن تعاونكى‬

‫انباحث‬

‫احًد ونيد أبو سعدة‬

‫‪Ahmedwaleeds93@gmail.com‬‬

‫‪1545325950‬‬

‫‪70‬‬
Research Title

Nurses' Knowledge and Perception Regarding the Implementation of Triage System at

Pediatric Emergency Department in Gaza Strip

General Goal

The aim of this study is to assess nurse's knowledge and perception regarding the
implementation of triage system in pediatric emergency department at Gaza Strip.

Specific objectives

1- To determine the nurses' knowledge about the triage of patients.

2- To identify the nurses' perception about triage system.

3- To identify the challenges for implementation of pediatric triage system

4- To Investigate the relationship between nurse's knowledge level and their perception

about triage implementation.

5- To investigate the relationship between nurse's knowledge and their qualification

6- To identify the relationship between nurse's knowledge and their site of work

7- To observe the relationship between nurse's knowledge and their sociodemographic

characteristics

8- To investigate the relationship between nurse's perception and their sociodemographic

characteristics

9- To investigate the relationship between nurse's perception and their qualification

10- To suggest recommendations for t h e further improvement of the newly

implemented triage system.

71
 ‫ال‬ ‫نعى‬ ‫انًحور األول‪ :‬يستوى انًعرفت‬
‫ريق‪ٞ‬ذ ٍذبظشاد ّظش‪ٝ‬خ ٗػَي‪ٞ‬خ د٘ه ّظبً ػَو اّظبً اىزش‪ٝ‬بط ف‪ ٜ‬قغٌ اىط٘اسئ‬ ‫‪.1‬‬
‫أٍيل اىَؼشفخ اىنبف‪ٞ‬خ د٘ه أى‪ٞ‬خ ػَو ّظبً اىزش‪ٝ‬بط ف‪ ٜ‬قغٌ اىط٘اسئ‬ ‫‪.2‬‬
‫ىذ‪ ٛ‬اىَقذسح ػي‪ ٚ‬ششح أى‪ٞ‬خ ػَو ّظبً اىفشص ىيضٍالء األخش‪ ِٝ‬ث٘ظ٘ح‬ ‫‪.3‬‬
‫أعزط‪ٞ‬غ اىق‪ٞ‬بً ثبىَٖبً اىزَش‪ٝ‬ع‪ٞ‬خ ف‪ ٜ‬صبىخ اىفشص اىطج‪ ٜ‬ػي‪ ٚ‬أعبط ٍؼشفخ ربٍخ‬
‫‪.4‬‬
‫ثْظبً اىزش‪ٝ‬بط‬
‫أعزط‪ٞ‬غ اىزَ‪ٞٞ‬ض ث‪ ِٞ‬ثطبقبد ّظبً اىزش‪ٝ‬بط ٗاىق‪َٞ‬خ اىضٍْ‪ٞ‬خ ٗاألٗى٘‪ٝ‬خ ىنو ٍْٖب‬ ‫‪.5‬‬
‫‪ٝ‬ؼزَذ ّظبً اىزش‪ٝ‬بط ػي‪ ٚ‬فشص اىذبالد ثجطبقبد راد أى٘اُ ٍخزيفخ ٍزفق ػي‪ٖٞ‬ب‬
‫‪.6‬‬
‫ػبىَ‪ٞ‬ب‬
‫ىذ‪ٍ ٛ‬ؼشفخ ربٍخ ثبىق‪َٞ‬خ اىضٍْ‪ٞ‬خ ىالّزظبس اىََنْخ ىنو ىُ٘ ػي‪ ٚ‬دذح‬ ‫‪.7‬‬
‫اىَش‪ٝ‬ط صبدت اىجطبقخ اىذَشاء ‪َٝ‬نِ أُ ‪ْٝ‬زظش ىغب‪ٝ‬خ عبػخ ىزيق‪ ٚ‬اىشػب‪ٝ‬خ اىطج‪ٞ‬خ‬ ‫‪.8‬‬
‫اىَش‪ٝ‬ط صبدت اىجطبقخ اىصفشاء ‪َٝ‬نِ أُ ‪ْٝ‬زظش ىغب‪ٝ‬خ صالس عبػبد ىزيق‪ٜ‬‬
‫‪.9‬‬
‫اىشػب‪ٝ‬خ اىطج‪ٞ‬خ‬
‫اىَش‪ٝ‬ط صبدت اىجطبقخ اىغ٘داء ال ‪ٝ‬ذزبط سػب‪ٝ‬خ أٗ رذخو غج‪ٜ‬‬ ‫‪.10‬‬
‫اىَش‪ٝ‬ط صبدت اىجطبقخ اىخعشاء ‪ٝ‬ذزبط رذخو غج‪ ٜ‬ػبجو ٗف٘س‪ٛ‬‬ ‫‪.11‬‬
‫غير‬
‫غير‬ ‫يوافق‬
‫يوافق‬ ‫يحايد‬ ‫يوافق‬ ‫انًحور انثاني‪ :‬يستوى انتصور‬
‫يوافق‬ ‫بشدة‬
‫بشدة‬
‫‪ٝ‬إصش ّظبً اىزش‪ٝ‬بط ػي‪ ٚ‬ج٘دح اىشػب‪ٝ‬خ اىصذ‪ٞ‬خ ف‪ٜ‬‬
‫‪.12‬‬
‫أقغبً اىط٘اسئ ثشنو مج‪ٞ‬ش‬
‫‪ٝ‬يؼت اىزش‪ٝ‬بط دٗس مج‪ٞ‬ش ف‪ ٜ‬اى٘ص٘ه ىشظ‪ٚ‬‬
‫‪.13‬‬
‫اىَشظ‪ٗ ٚ‬ػبئالرٌٖ‬
‫‪ٝ‬قً٘ أعبط ّظبً اىزش‪ٝ‬بط ػي‪ ٚ‬االعزغاله األٍضو‬
‫‪.14‬‬
‫ىإلٍنبّ‪ٞ‬بد ٗاىقذساد‬
‫‪ٝ‬زطيت رطج‪ٞ‬ق ّظبً اىزش‪ٝ‬بط ئٍنبّ‪ٞ‬بد ٍٗجٖ٘داد‬
‫‪.15‬‬
‫ظخَخ ٗمج‪ٞ‬شح‬
‫‪ٝ‬ؼزجش ّظبً اىزش‪ٝ‬بط ٍِ أعظ عالٍخ اىَشظ‪ ٚ‬ف‪ٜ‬‬
‫‪.16‬‬
‫أقغبً اىط٘اسئ‬
‫‪ٝ‬ؼزجش ّظبً اىزش‪ٝ‬بط أعي٘ثب ّبجؼب ف‪ ٜ‬اىزؼبٍو ٍغ‬
‫‪.17‬‬
‫اصددبً اىذبالد ف‪ ٜ‬قغٌ اىط٘اسئ‬
‫أؤٍِ ثإَٔ‪ٞ‬خ دٗس اىََشض ف‪ ٜ‬رطج‪ٞ‬ق ّظبً‬
‫‪.18‬‬
‫اىزش‪ٝ‬بط ف‪ ٜ‬قغٌ اىط٘اسئ‬
‫‪ٝ‬غزط‪ٞ‬غ اىطبقٌ اىزَش‪ٝ‬ع‪ٗ ٜ‬اىطج‪ ٜ‬ثبىغ‪ٞ‬طشح ػي‪ٚ‬‬
‫رضادٌ اىذبالد ف‪ ٜ‬قغٌ اىط٘اسئ ثذُٗ رفؼ‪ٞ‬و ّظبً‬ ‫‪.19‬‬
‫اىزش‪ٝ‬بط‬
‫أؤٍِ ثبىذٗس اىشئ‪ٞ‬غ‪ ٜ‬ىْظبً اىزش‪ٝ‬بط ف‪ ٜ‬رقذ‪ٌٝ‬‬
‫اىشػب‪ٝ‬خ اىصذ‪ٞ‬خ اىطبسئخ ف‪ ٜ‬أقغبً اعزقجبه‬ ‫‪.20‬‬
‫األغفبه دغت األٗى٘‪ٝ‬خ‬
‫أٍزيل اىشغجخ ىيَشبسمخ ف‪ ٜ‬دٗساد ٍٗإرَشاد‬
‫ٗأّشطخ ػيَ‪ٞ‬خ رؼضص إَٔ‪ٞ‬خ رطج‪ٞ‬ق ّظبً اىزش‪ٝ‬بط‬ ‫‪.21‬‬
‫ف‪ ٜ‬أقغبً اىط٘اسئ‬
‫أّب ػي‪ ٚ‬قْبػخ ثعشٗسح رفؼ‪ٞ‬و ّظبً اىزش‪ٝ‬بط ف‪ٜ‬‬
‫ئداسح دبالد االصددبً اىَشظ‪ٞ‬خ ف‪ ٜ‬قغٌ اعزقجبه‬ ‫‪.22‬‬
‫األغفبه‬

‫‪72‬‬
 ‫غير‬
‫غير‬ ‫يوافق‬
‫يوافق‬ ‫يحايد‬ ‫يوافق‬ ‫انًحور انثانث‪ :‬انتحدياث وانًعيقاث‬
‫يوافق‬ ‫بشدة‬
‫بشدة‬
‫أػزقذ أُ ْٕبك رذذ‪ٝ‬بد ٍٗؼ‪ٞ‬قبد مج‪ٞ‬شح عز٘اجٔ‬
‫‪.23‬‬
‫رفؼ‪ٞ‬و ّظبً اىزش‪ٝ‬بط ف‪ ٜ‬قغٌ اعزقجبه األغفبه‬
‫ث‪ٞ‬ئخ اىؼَو ٍْبعجخ ٍٗالئَخ إلٍنبّ‪ٞ‬خ رفؼ‪ٞ‬و ّظبً‬
‫‪.24‬‬
‫اىزش‪ٝ‬بط‬
‫أؤٍِ ث٘ج٘د قْبػخ ٗسغجخ ىذ‪ ٙ‬أصذبة اىقشاس‬
‫‪.25‬‬
‫ثزفؼ‪ٞ‬و ّظبً اىزش‪ٝ‬بط‬
‫اىنبدس اىزَش‪ٝ‬ع‪ ٜ‬اىَز٘اجذ دبى‪ٞ‬ب ف‪ ٜ‬قغَ‪ٝ ٜ‬نف‪ٜ‬‬
‫‪.26‬‬
‫ىزطج‪ٞ‬ق ّظبً اىزش‪ٝ‬بط‬
‫اىنبدس اىزَش‪ٝ‬ع‪ ٜ‬ىذ‪ ٔٝ‬اىذافغ اىذق‪ٞ‬ق‪ ٜ‬ىزطج‪ٞ‬ق ّظبً‬
‫‪.27‬‬
‫اىزش‪ٝ‬بط‬
‫اصددبً اىذبالد ‪ٝ‬ؼزجش أدذ ٍؼ‪ٞ‬قبد رطج‪ٞ‬ق ّظبً‬
‫‪.28‬‬
‫اىزش‪ٝ‬بط‬
‫أػزقذ ثأُ اىجَٖ٘س ىذ‪ ٔٝ‬فنشح مبف‪ٞ‬خ د٘ه اى‪ٞ‬خ ػَو‬
‫‪.29‬‬
‫ّظبً اىزش‪ٝ‬بط‬
‫ْٕبك سغجخ دق‪ٞ‬قخ ىذ‪ ٙ‬اىجَٖ٘س رذػ٘ ىزفؼ‪ٞ‬و ّظبً‬
‫‪.30‬‬
‫اىزش‪ٝ‬بط‬
‫‪َٝ‬زيل اىقغٌ ٍ٘اسد ٍبد‪ٝ‬خ رغَخ ثزطج‪ٞ‬ق ّظبً‬
‫‪.31‬‬
‫اىزش‪ٝ‬بط ثغٖ٘ىخ ٗثذُٗ ئػبقخ‬
‫‪ٝ‬ز٘فش ػْبصش ثشش‪ٝ‬خ ىعجػ األٍِ رغزط‪ٞ‬غ‬
‫اىغ‪ٞ‬طشح ػي‪ ٚ‬أ‪ ٛ‬دبىخ ٍِ اىف٘ظ‪ ٚ‬ف‪ ٜ‬صبىخ‬
‫‪.32‬‬
‫االّزظبس ٗرغبٌٕ ثبالىزضاً ف‪ ٜ‬اىَذذداد اىضٍْ‪ٞ‬خ‬
‫ىْظبً اىزش‪ٝ‬بط‬
‫‪٘ٝ‬جذ ف‪ ٜ‬صبىخ االّزظبس الفزبد ر٘ػ٘‪ٝ‬خ مبف‪ٞ‬خ‬
‫‪.33‬‬
‫رششذ اىجَٖ٘س ثأى‪ٞ‬خ ػَو ّظبً اىزش‪ٝ‬بط‬
‫‪٘ٝ‬جذ ٗقذ مبف‪ ٜ‬ىذ‪ ٙ‬ىََشظ‪ ِٞ‬ىزطج‪ٞ‬ق ّظبً‬
‫‪.34‬‬
‫اىزش‪ٝ‬بط ف‪ ٜ‬قغٌ غ٘اسئ األغفبه‬
‫ظغػ اىؼَو ف‪ ٜ‬قغٌ اىط٘اسئ ‪ٝ‬ؼ‪ٞ‬ق رطج‪ٞ‬ق ّظبً‬
‫‪.35‬‬
‫اىزش‪ٝ‬بط ثْجبح‪.‬‬

‫‪73‬‬
Annex 2: Helsinki Approval

74
Annex 3: Ministry of Health Approval

75
Annex 4: Action Plan

The study takes 10 months; from Dec., 2018 till October 2019. This period was
accomplished as illustrated in the below time table:

Time Table Activities:

Activity Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2018 2019 2019 2019 2019 2019 2019 2019 2019 2019 2019 2019 2019

Development ▀ ▀
of proposal

Ethical
clearance
from Helsinki ▀
committee

MOH ▀
approval

Piloting ▀

Data ▀ ▀
collection

Data entry ▀

Data analysis ▀ ▀

Research ▀ ▀
writing

Dissemination ▀
of findings

76
‫العنوان‪ :‬معرفة وادراك الممرضين فيما يتعلق بتطبيق نظام الفرز في أقسام طوارئ األطفال في قطاع‬
‫غزة‬

‫إعداد‪ :‬أحمد وليد أبو سعدة‬

‫إشراف‪ :‬د‪ .‬محمد الجرجاوي‬

‫ملخص الدراسة‬

‫يعتبر الفرز وظيفة ساساةيل لمرررنةيي أةس س اةسم الطةوار ‪ ،‬كرةس سي رعرأةل الرررنةيي لةو الفةرز هةس‬
‫الرفتةةسف أةةس هرميةةل اتقةةسا ال ة ار ار ‪ .‬تهة ا ال اراة تلةةم ت يةةيم الرعرأة والتصةةو ار القسصة ب ظةةسم الفةةرز‬
‫التةةس ة تة ر همةيهم‪ .‬و ة تةم تصةةريم‬ ‫الرررنةيي العةةسرميي أةس س اةةسم ااةت بس الطفةةس والرلة ا‬ ‫لة‬
‫اللكورية أةس طةسع ةز ‪.‬‬ ‫ال راا الوصفي التلميمي أةس س اةسم طةوار الطفةس أةس اريةت الراتاةفيس‬
‫هي ة ة ال اراة ة ر ةةي اري ةةت الرررن ةةيي الع ةةسرميي أ ةةس س ا ةةسم طة ةوار الطف ةةس أ ةةس الراتا ةةفيس‬ ‫تكو ة ة‬
‫بتص ةةريم‬ ‫ةةسم البسلة ة‬ ‫اللكوري ة ب ط ةةسع ةةز والب ةةسل هة ة هم ‪ 111‬رر ةةرم ورررنة ة ‪ .‬لار ةةت البيس ةةس‬
‫بإاراء راا‬ ‫ااتبس لهاا الغرم‪ ،‬و تم هرنهس همم راروه ري الرلكريي‪ ،‬كرس تم اقتبسر ال بس‬
‫ااتق م‬ ‫تسئج اقتبسر سلفس ررني ‪ .‬لتلمي البيس س‬ ‫ااتطالهي همم هي ري ‪ 11‬ااتبس س ‪ ،‬و كس‬
‫بر سرج الرزم اإللصسئي )‪.(SPSS Version 22‬‬ ‫البسل‬

‫‪،‬‬ ‫التكة ة ار ار ‪ ،‬ال اةةل الرئوية ة ‪ ،‬الرتواةةط اللاةةسبس‪ ،‬اا لةةراا الرعيةةسر ‪ ،‬اقتب ةةسر‬ ‫وااةةتق م البسل ة‬
‫ت ةةسئج ال اراةة سي ‪ %8..7‬ر ةةي‬ ‫اقتب ةةسر تلميةة التب ةةسيي اللة ةس ‪ ،‬واقتب ةةسر بيرا ةةوي لمعال ةةس ‪ ،‬وبي ة ة‬
‫الرا ةةسركيي أ ةةس ال ارا ة ة ك ةةس وا ر ةةي الةةةاكور‪ %.8.6 ،‬ك ةةس وا رت ةةزوايي‪ %.. ،‬لسصة ةةميي هم ةةم را ة ة‬
‫البكةةسلوريوس أةةس الترةريم‪ %41.4 ،‬لة يهم قبةةر س ة رةةي ‪ 6‬اة وا ‪ %.1.. ،‬كةةس وا رررنةةيي ب راة‬
‫ال تةةسئج سي ‪%66‬‬ ‫صةةبسلس‪ ،‬راةةسئس‪ ،‬ليمةةس ‪ ،‬وبي ة‬ ‫الرقتمطة‬ ‫لكةةيم‪ %41 ،‬يعرمةةوي ب ظةةسم الر سوبةةس‬
‫الفةةرز‪ .‬وسظهةةر الراةةسركيي أةةس ال اراة راةةتو‬ ‫رةةي الرررنةةيي التل ةوا ببر ةةسرج تة ريبس قةةسف بعرميةةس‬
‫لةةو بر ةةسرج الفةةرز‪ ،‬كرةةس سي تصةةوراتهم لبر ةةسرج الفةةرز كس ة‬ ‫أةةول الرتواةةط ‪ %8.‬رةةي الرعمورةةس‬
‫التةس توااةل الرررنةيي‬ ‫‪ ،%71‬أةس لةيي تبةيي واةو راةتو رتواةط رةي التلة يس‬ ‫ب را هسلية بمغة‬
‫أس تطبيل بر سرج الفرز‪.‬‬

‫التس‬ ‫ال تلصسئيسً بيي تصو ار الرررنيي تاس بر سرج الفرز والتل يس‬ ‫وسظهر ال تسئج واو هال‬
‫توااههم أس تطبيل بر سرج الفرز‪.‬‬

‫‪77‬‬
‫ارتفةةسع راةةتو الرعرأ ة ببر ةةسرج الفةةرز ور هةةس تم ةةس ت ة ريل‬ ‫وسظهةةر ال تةةسئج واةةو ه ة هوار ة س‬
‫را البكسلوريوس‪ ،‬رئيس ام‪ ،‬والايي يعرموي أس راتافم ز الوروبةس‪.‬‬ ‫قسف ببر سرج الفرز لرم‬
‫سهرسرهم بيي ‪ 67 – 17‬ا ‪ ،‬وري اكسي ز‬ ‫الرررنيي الايي تراول‬ ‫ل‬ ‫وكسي راتو الرعرأ س‬
‫الرررنةيي الغيةر رتةزوايي‪ ،‬والةايي ياةك وي رلسأظة رأة‬ ‫سهمم لة‬ ‫والارس ‪ .‬وكسي راتو التل يس‬
‫تعةز لكة رةي‬ ‫وقس يو س‪ ،‬أس ليي لم توا أرول أس ك ري راتو الرعرأ ‪ ،‬التصةو ار ‪ ،‬والتلة يس‬
‫القبر‪ ،‬و ظسم الر سوبس ‪.‬‬ ‫الا س‪ ،‬ا وا‬

‫ال اراة اللساة لواةةو بةرارج ت ريبية لتلاةةيي رعرأة ورهةةس ار الرررنةةيي بقصةةوف بر ةةسرج‬ ‫وسوصة‬
‫اللكورية ب طةةسع ةةز وتطبيةةل‬ ‫الفةةرز لمررنةةم الرتةةر يي همةةم س اةةسم طةوار الطفةةس أةةس الراتاةةفيس‬
‫ظسم الفرز أس س اسم اات بس الطفس ‪.‬‬

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