4466 137060 1 PB

Relationships between Triage Knowledge, Training, Working
Experiences and Triage Skills among Emergency Nurses in East Java,

Indonesia(Hubungan antara Pengetahuan Triase, Pelatihan,
Pengalaman Kerja dan Keterampilan Triase pada Perawat Gawat
Darurat di Jawa Timur, Indonesia)
Mukhamad Fathoni, RN1, Hathairat Sangchan, RN., Ph.D2, Praneed Songwathana, RN., Ph.D3
Abstract
Background: Since there are increased numbers of clients with traumatic injuries and non-
traumatic cases in the emergency department in Indonesia, triage skill is an essential
competency required for the emergency nurses.
Purposes: This study aimed to examine the level of perceived triage skills and the
relationship between knowledge, training, working experience and perceived triage skills among
emergency nurses.
Method: Two hundred and sixty six emergency room (ER) nurses working in two
secondary and two tertiary public hospitals in East Java Province, Indonesia, were
recruited by purposive sampling. Data were collected using a set of questionnaires which
included the Demographic Data including training and working experiences, Triage
Knowledge Questionnaire (TKQ) and Triage Skill Questionnaire (TSQ). The contents of
questionnaires were validated by three experts and tested for reliability. The correlation
coefficient for the TKQ was 0.99 and Cronbach’s alpha coefficient of the TSQ was 0.93.
The collected data were analyzed using descriptive statistics including Pearson’s product-
moment correlation to examine the relationship.( Dua ratus enam puluh enam perawat ruang
gawat darurat (IGD) yang bekerja di dua rumah sakit umum sekunder dan tersier di
Provinsi Jawa Timur, Indonesia, direkrut dengan purposive sampling. Data dikumpulkan
dengan menggunakan seperangkat kuesioner yang mencakup Data Demografi termasuk
pelatihan dan pengalaman kerja, Kuesioner Pengetahuan Triase (TKQ) dan Kuesioner
Keterampilan Triase (TSQ). Isi angket divalidasi oleh tiga ahli dan diuji reliabilitasnya.
Koefisien korelasi untuk TKQ adalah 0,99 dan koefisien alpha Cronbach dari TSQ adalah
0,93. Data yang terkumpul dianalisis menggunakan statistik deskriptif termasuk korelasi
product-moment Pearson untuk menguji hubungan tersebut.)
Result: The results showed that the majority of subjects were female (71.4%) with aged
of 22 – 40 years (79.3%), educated to diploma level (94.4%). All subjects had attended
Basic Life Support (BLS) and Advanced Life Support (ACLS), and about half of them had
greater than 5 years working experiences in ED. Overall perceived triage skill was at a moderate
level with the mean score of 75.12 (SD = 11.23). There were significantly positive correlations
between triage skill and working experience (r = .27, p < .01), training experience (r =
.37, p < .01), and triage knowledge (r = .38, p < .01).
Conclusion: The findings provide a better understanding of triage skills among ER nurses
Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 1

and suggest that the continuing education and training courses related to triage and
advanced management of medical emergencies for ER nurses are required in order to
increase and update the triage skills in enhancing the quality of emergency care and patient
safety. (Temuan ini memberikan pemahaman yang lebih baik tentang keterampilan triase
di antara perawat UGD dan menyarankan bahwa pendidikan berkelanjutan dan kursus
pelatihan terkait dengan triase dan manajemen lanjutan kedaruratan medis untuk
perawat UGD diperlukan untuk meningkatkan dan memperbarui keterampilan triase
dalam meningkatkan kualitas kegawatdaruratan. perawatan dan keselamatan pasien.)

Relationships between Triage Knowledge, Training, Working Experiences and Triage Skills among Emergency
Nurses in East Java, Indonesia
Introduction
Emergency department (ED) generally provides immediate care 24 hours
everyday. The unpredictable numbers of patients coming to ED suffer from various
conditions with unknown severity, urgency, and definite diagnosis. The patients who are
suffering from life threatening conditions, such as cardiac arrest, airway obstruction, and
shock should be prioritized to provide them an early immediate care to save their lives. (Unit
Gawat Darurat (IGD) umumnya memberikan perawatan segera 24 jam setiap hari.
Jumlah pasien yang datang ke UGD yang tidak dapat diprediksikan menderita berbagai
kondisi dengan tingkat keparahan, urgensi, dan diagnosis yang belum diketahui pasti.
Pasien yang menderita kondisi yang mengancam jiwa, seperti serangan jantung, obstruksi
jalan napas, dan syok harus diprioritaskan untuk memberikan perawatan segera dini
untuk menyelamatkan nyawa mereka.)However, the over crowdedness of patients visiting
to ED can have an impact on the quality of care by diversifying the resources intended for
patients, which are in need of emergency care to the individuals who have potentially less urgent
needs (Milbrett & Halm, 2009). There is consensus that triage is an essential procedure in ED as
an effective system for reducing waiting times and ensuring that all patients visiting to ED
receives the appropriate treatments (Namun, kepadatan pasien yang berkunjung ke UGD
dapat berdampak pada kualitas perawatan dengan mendiversifikasi sumber daya yang
ditujukan untuk pasien, yang membutuhkan perawatan darurat kepada individu yang
memiliki kebutuhan yang berpotensi kurang mendesak (Milbrett & Halm, 2009). . Ada
konsensus bahwa triase adalah prosedur penting di UGD sebagai sistem yang efektif untuk
mengurangi waktu tunggu dan memastikan bahwa semua pasien yang berkunjung ke
UGD menerima perawatan yang tepat.)

ED triage is a type of triage that emergency nurses perform daily. The goal is to
identify the most severe patients who are in need of immediate care (Qureshi & Venema,
2007). ED triage composes of primary and secondary triage decision (Gerdtz & Bucknall, as
cited in Considine, Botti, & Thomas, 2007). Primary triage decision is related to the procedures
of the primary assessment and allocation the patients to appropriated treatment. Secondary triage
decision is related to initiation of nursing intervention, and provides comfort to the patients
(Gerdtz & Bucknall, as cited in Considine et al., 2007). However, the primary triage skill of the
emergency nurses is more focused as it is included the procedures of rapid assessment,
patient categorization, and patient allocation (Proehl, 2007; Sharma, 2005). For the effectiveness
of the ER triage, all above procedures require the ability of making decision in accuracy and
timely. Triage skill is one of the most competencies required for the emergency nurses

(Andersson, Omberg, & Svedlund, 2006; Gerdtz & Bucknall, 2001; Gilboy, Travers, &
Wuerz, 1999). Previous studies have shown that the main factor related to triage skill of the
emergency nurses was triage knowledge (Andersson et al., 2006; Considine et al., 2007).
However, its relationships has yet to be explored among ER nurses in the countries
where have high workload and demands of care particularly in Indonesia.
As an example in one of the famous General Hospital in East Java province,
Indonesia to reflect the care situations, there are totally 74 emergency nurses allocated to
work in three shifts. About 20-25 emergency nurses provide services to 50-70 patients per
shift. The ratio of emergency nurses in triage room to patients each shift is 1: 25-35
approximately. According to the study by Wardhani (2001), it showed that the mortality rate in
the ED of East Java province was 26.4%. (Sebagai contoh di salah satu Rumah Sakit Umum
terkenal di Provinsi Jawa Timur, Indonesia untuk mencerminkan situasi perawatan, ada
74 perawat darurat yang dialokasikan untuk bekerja dalam tiga shift. Sekitar 20-25
perawat gawat darurat memberikan layanan kepada 50-70 pasien per shift. Rasio perawat
gawat darurat di ruang triase terhadap pasien setiap shift adalah sekitar 1: 25-35. Menurut
penelitian Wardhani (2001), menunjukkan angka kematian di UGD Provinsi Jawa Timur
sebesar 26,4%.)Since every hospital in Indonesia concerns the patient safety issue with the high
quality of care, it is necessary to examine emergency nurse’s triage skills and related factors such
as knowledge, training and working experience in ED. The study was conducted in an attempt to
provide useful information for improvement better triage skills among Indonesian emergency
nurses in the future.( Karena setiap rumah sakit di Indonesia memperhatikan masalah
keselamatan pasien dengan kualitas pelayanan yang tinggi, maka perlu untuk mengkaji
keterampilan triase perawat gawat darurat dan faktor-faktor terkait seperti pengetahuan,
pelatihan dan pengalaman kerja di IGD. Penelitian ini dilakukan dalam upaya
memberikan informasi yang berguna untuk peningkatan keterampilan triase yang lebih
baik di antara perawat darurat Indonesia di masa depan.)
Aim
The objectives of this study were to examine 1) the level of triage skills perceived by
emergency nurses and 2) the relationship between triage knowledge, training, working
experience and triage skill among emergency nurses in East Java province of Indonesia.
(Tujuan dari penelitian ini adalah untuk menguji 1) tingkat keterampilan triase yang dirasakan oleh
perawat gawat darurat dan 2) hubungan antara pengetahuan triase, pelatihan, pengalaman kerja dan
keterampilan triase pada perawat gawat darurat di provinsi Jawa Timur Indonesia.)

Method
Definition of Terms
Triage skills referred to the level of nurses’ perception of ability in making decision
accurately and timely in the following areas: (1) rapid assessment, (2) patient categorization, and
(3) patient allocation. It is measured by the Triage Skill Questionnaire (TSQ) developed based on
the literature review.( Keterampilan triase mengacu pada tingkat persepsi perawat tentang
kemampuan dalam membuat keputusan secara akurat dan tepat waktu di bidang-bidang
berikut: (1) penilaian cepat, (2) kategorisasi pasien, dan
(3) alokasi pasien. Diukur dengan Triage Skill Questionnaire (TSQ) yang dikembangkan
berdasarkan literature review. )
Triage knowledge referred to the level of factual and procedural knowledge required
for emergency nurses to perform rapid assessment, patient categorization, and patient
allocation. It is measured by the Triage Knowledge Questionnaire (TKQ) developed based on
the literature review.( Pengetahuan triase mengacu pada tingkat pengetahuan faktual dan
prosedural yang dibutuhkan perawat gawat darurat untuk melakukan pengkajian cepat,
kategorisasi pasien, dan alokasi pasien. Diukur dengan Triage Knowledge Questionnaire
(TKQ) yang dikembangkan berdasarkan literature review.)
Training experience referred to the numbers of time and the types of previous training
in triage and related topics in the past three years, such as attending short course, workshop, etc.
It is measured by using training index. (Pengalaman pelatihan mengacu pada jumlah waktu
dan jenis pelatihan sebelumnya dalam triase dan topik terkait dalam tiga tahun terakhir,
seperti menghadiri kursus singkat, lokakarya, dll. Diukur dengan menggunakan indeks
pelatihan)
Working experience referred to the numbers of months in working as emergency

nurses.
Research design and study framework

This study conducted using a descriptive correlational study to examine the
relationships among triage knowledge, training experience, working experience and triage
skills. The conceptual framework of this study was derived from the synthesis and the
integration of literature review in the area of emergency nursing.( Penelitian ini dilakukan
dengan menggunakan studi deskriptif korelasional untuk menguji hubungan antara
pengetahuan triase, pengalaman pelatihan, pengalaman kerja dan keterampilan triase.
Kerangka konseptual penelitian ini berasal dari sintesis dan integrasi tinjauan literatur di
bidang keperawatan darurat ) Triage skill in the ED was the performance of emergency nurse
using decision-making capability to prioritize patients into the right categories within a limited
space of time (Andersson et al., 2006; Gerdtz & Bucknall, 2001; Gilboy, 2005). The triage skill
includes rapid assessment, patient categorization, and patient

allocation (Keterampilan triase di UGD adalah kinerja perawat darurat menggunakan

kemampuan pengambilan keputusan untuk memprioritaskan pasien ke dalam kategori yang
tepat dalam ruang waktu yang terbatas (Andersson et al., 2006; Gerdtz & Bucknall, 2001;
Gilboy, 2005). Keterampilan triase meliputi penilaian cepat, kategorisasi pasien, dan
alokasi)
The triage knowledge was examined in terms of the factual knowledge and the
procedural knowledge, which are essential as the basic knowledge for the emergency
nurses to perform the triage effectively (Patel et al., 2002). Factual knowledge is knowledge
about a fact or set of facts condition without wide understanding such as anatomy,
physiology, pathophysiology, and common illness of the patients visiting to ED.
(Pengetahuan triase diperiksa dalam hal pengetahuan faktual dan pengetahuan
prosedural, yang penting sebagai pengetahuan dasar bagi perawat darurat untuk
melakukan triase secara efektif (Patel et al., 2002). Pengetahuan faktual adalah
pengetahuan tentang suatu fakta atau sekumpulan fakta kondisi tanpa pemahaman yang
luas seperti anatomi, fisiologi, patofisiologi, dan penyakit umum pasien yang berkunjung
ke IGD. ) Procedural knowledge is a kind of knowing related to how to perform actions in
many activities such as nursing techniques using in primary triage. The training experiences can
improve the nurse’s triage skill for identifying the patient’s scale of urgency, diagnosing
the patient, and providing emergency nursing intervention in ED
Triage Knowledge
Triage Skill:
Rapid assessment
Patient categorization
Triage Experience Patient allocation
Working Experience
(Pengetahuan prosedural adalah jenis pengetahuan yang berkaitan dengan

bagaimana melakukan tindakan dalam berbagai aktivitas seperti teknik keperawatan yang
digunakan dalam triase primer. Pengalaman pelatihan dapat meningkatkan keterampilan
triase perawat untuk mengidentifikasi skala urgensi pasien, mendiagnosis pasien, dan
memberikan intervensi keperawatan gawat darurat di IGD ) (Chung, 2005). To be skillful
in triage, the emergency nurses are required to participate in the training program regarding
triage and the related topics, and should be refreshed every one to three years. The working
experience refers to the duration of working as the emergency nurses. Figure 1 presents the
conceptual framework of this study. The factors related to triage skill are the level of triage
knowledge, training experience, and working experience. (Agar terampil dalam triase,
perawat gawat darurat wajib mengikuti program pelatihan tentang triase dan topik
terkait, dan harus disegarkan setiap satu hingga tiga tahun. Pengalaman kerja mengacu
pada lamanya bekerja sebagai perawat gawat darurat. Gambar 1 menyajikan kerangka
konseptual penelitian ini. Faktor-faktor yang berhubungan dengan keterampilan triase
adalah tingkat pengetahuan triase, pengalaman pelatihan, dan pengalaman kerja. )
Figure: 1 Conceptual Framework of the Study

The sample and settings
The population were nurses working in ED in both tertiary and secondary
hospitals. Only government hospitals were selected for the target setting based on the
following reasons: 1) it provides public emergency services in East Java province as
referral hospitals for the East area of Indonesia, 2) the ratio of patients to nurses and doctors
are higher than private hospital, 3) working environment is different from private hospital. Two
tertiary (Hospital A and B) and two secondary public hospitals (Hospital C and D) in East Java
province were conveniently selected to recruit estimated sample size of 306 subjects
(including additional 10% to compensate for expected attrition). (Populasi adalah perawat
yang bekerja di IGD baik di rumah sakit tersier maupun sekunder. Hanya rumah sakit
pemerintah yang dipilih untuk penetapan target berdasarkan alasan berikut: 1)
menyediakan layanan darurat publik di provinsi Jawa Timur sebagai rumah sakit rujukan
untuk wilayah Indonesia Timur, 2) rasio pasien terhadap perawat dan dokter lebih tinggi
daripada swasta rumah sakit, 3) lingkungan kerja berbeda dengan rumah sakit swasta.
Dua tersier (Rumah Sakit A dan B) dan dua rumah sakit umum sekunder (Rumah Sakit C
dan D) di provinsi Jawa Timur dipilih dengan mudah untuk merekrut perkiraan ukuran
sampel 306 subjek (termasuk tambahan 10% untuk mengkompensasi pengurangan yang
diharapkan). All nurses working in emergency department of those hospitals were recruited to
be the samples. The inclusion criterion was those nurses who had the nursing education
background at least diploma in nursing level. From 40 out of 306 emergency nurses who
had under diploma degree (Sekolah Perawat Kesehatan or nursing education at the level of
senior high school) were excluded. Thus, 266 emergency nurses were met the criteria.

(Semua perawat yang bekerja di unit gawat darurat rumah sakit tersebut
direkrut untuk menjadi sampel. Kriteria inklusi adalah perawat yang memiliki latar
belakang pendidikan keperawatan minimal diploma keperawatan. Dari 40 dari 306
perawat gawat darurat yang memiliki gelar sarjana (Sekolah Perawat Kesehatan atau
pendidikan keperawatan di tingkat sekolah menengah atas) dikeluarkan. Dengan
demikian, 266 perawat gawat darurat memenuhi kriteria.)
Instruments
Data were collected using a set of questionnaires: 1) Demographic Data Sheet
(DDS) including training and working experience; 2) Triage Skill Questionnaire (TSQ) was a
37-item questionnaire with three dimensions including rapid assessment, patient categorization,
and patient allocation. (Data dikumpulkan dengan menggunakan seperangkat kuesioner: 1)
Demographic Data Sheet (DDS) termasuk pelatihan dan pengalaman kerja; 2) Triage Skill
Questionnaire (TSQ) adalah kuesioner 37 item dengan tiga dimensi meliputi penilaian
cepat, kategorisasi pasien, dan alokasi pasien). Subjects were asked to respond to each item
using 1-5 rating scale: 1 = need improvement, 2 = poor, 3 = fair, 4 =good, and 5 = very good.
The possible range of the total score was 37-185. The total score was converted to percentage.
Using the criterion- referenced, the following score was interpreted as: < 60% = low level of
triage skills, 60-80% =

moderate level of triage skills, and > 80% = high level of triage skills; 3) Triage Knowledge
Questionnaire (TKQ) consists of 35 items. (Subjek diminta untuk menanggapi setiap item
menggunakan skala penilaian 1-5:
1 = perlu perbaikan,
2 = miskin,
3 = adil,
4 = baik, dan
5 = sangat baik. Rentang yang mungkin dari total skor adalah 37-185. Skor total diubah
menjadi persentase. Dengan menggunakan acuan kriteria, skor berikut diinterpretasikan
sebagai:
< 60% = keterampilan triase tingkat rendah,
60-80% = keterampilan triase tingkat sedang, dan
> 80% = keterampilan triase tingkat tinggi;
3) Kuesioner Pengetahuan Triase (TKQ) terdiri dari 35 item. ) Each question has four
choices. The correct answer of each item was get 1 score and incorrect answer was get 0 score.
The higher scores indicate that the nurse had more knowledge. The possible range of total
score of triage knowledge is 0-35.The total score was calculated to percentage. Using the
criterion-referenced, the total score less than 60% was low level of knowledge, 60-80 % was
moderate level of knowledge and more than 80% was high level of knowledge. (Setiap
pertanyaan memiliki empat pilihan. Jawaban yang benar setiap butir soal mendapat skor 1
dan jawaban salah mendapat skor 0. Semakin tinggi skor menunjukkan bahwa perawat

memiliki pengetahuan yang lebih. Rentang skor total pengetahuan triase yang mungkin
adalah 0-35. Skor total dihitung dalam persentase. Dengan menggunakan acuan kriteria,
skor total kurang dari 60% tingkat pengetahuan rendah, 60-80% tingkat pengetahuan
sedang dan lebih dari 80% tingkat pengetahuan tinggi.)
Training experience in the past three years was interpreted using training index
with the formula: number of training x number of times. The higher score was reflected
the higher training experience. Working experience was calculated using months of
working as emergency nurses. The longer months of working experience reflects the higher
experience. (Pengalaman pelatihan dalam tiga tahun terakhir diinterpretasikan
menggunakan indeks pelatihan dengan rumus: jumlah pelatihan x jumlah kali. Semakin
tinggi skor mencerminkan pengalaman pelatihan yang lebih tinggi. Pengalaman kerja
dihitung menggunakan bulan bekerja sebagai perawat darurat. Semakin lama bulan
pengalaman kerja mencerminkan pengalaman yang lebih tinggi. ) The instruments were
translated from English to Javanese and back translation from Javanese to English by two
skilled bilingual translators from Nursing Science Program, Brawijaya University Malang
Indonesia. The content validity of the questionnaires was evaluated by three experts. The revised
version in accordance with recommendation of the experts was tested reliability among 20
emergency nurses. The internal consistency of the TSQ was analysed using Cronbach’s
alpha coefficient, yielding .93. By test-retested method, the correlation coefficient of the TKQ
was .99.
Data collection
Data were conducted during January to February 2010 after approval from the
Intuitional Review Board (IRB) of the Faculty of Nursing, Prince of Songkla University,
the ethical committee of medical research medical faculty Brawijaya University, and the
permission from directors of the hospitals. Due to limited authority of the principal

researcher, the head nurses in ED from each hospital had to be approached for introducing the
ED nurses to participate in the study. The researcher maintained the anonymity of the
subjects by using code and all data were kept confidential. The subjects were asked to
answer the questionnaires and return to the researcher within one week. The data were analyzed
by descriptive statistics, and the relationships of the mean scores were analyzed by Pearson’s
product moment correlation.
Results
Demographic characteristics
Of 266 emergency nurses, the majority (71.40%) was female, with a mean age
33.37 years (SD = 7.54). Most of the subjects (94.40%) had educated of diploma degree.
The rest (5.60%) had completed bachelor in nursing. Three fourth of subjects (75.60%)
has been working in tertiary hospitals; the rest (24.40%) has been working in secondary
hospitals. Subjects from Hospital A-D were 176, 64, 35 and 31 respectively (Dari 266
perawat gawat darurat, mayoritas (71,40%) adalah perempuan, dengan usia rata-rata
33,37 tahun (SD = 7,54). Sebagian besar subjek (94,40%) berpendidikan diploma.
Sisanya (5,60%) telah menyelesaikan sarjana keperawatan. Tiga perempat subjek
(75,60%) telah bekerja di rumah sakit tersier; sisanya (24,40%) telah bekerja di rumah
sakit sekunder. Subjek dari Rumah Sakit A-D masing-masing adalah 176, 64, 35 dan 31 ).
Regarding to the tertiary hospitals, there were 25 – 40 emergency nurses per shift. Two or three
of those nurses had rotated to work in the triage room, in which the ratio of triage nurse to patient
was 1: 30-40. In Hospital A, a physician had contributed in triage room; but none in
Hospital (Untuk rumah sakit tersier, ada 25 – 40 perawat darurat per shift. Dua atau tiga
perawat tersebut dirotasi untuk bekerja di ruang triase, dimana rasio perawat triase

terhadap pasien adalah 1:30-40. Di Rumah Sakit A, seorang dokter telah berkontribusi di
ruang triase; tapi tidak ada di Rumah Sakit )
B. During the 2010 survey, approximately 50 – 100 cases per shift both traumatic and non
traumatic problems were treated at ED. The common traumatic cases from the most to
the least were traumatic brain injury, urinary tract injuries, open wound of extremities,
maxillofacial injuries, fracture of clavicle, and multiple organ injuries. The common non-
traumatic cases from the most to the least were diarrhoea, acute pharyngitis, acute upper
respiratory infection, fever, dyspepsia, severe hypertension, stroke, spontaneous vertex
delivery, asthma, gastritis, gastroenteritis measles, renal failure, and DHF.

In the secondary hospitals (Hospital C and D), there were 6-7 emergency nurses per
shift. A general physician and a nurse were shared responsibility in the triage room, in
which the ratio of triage nurse to patient was 1: 25-40 approximately. The common problems
of the patients visiting to ED from the most to the least were fever, head injury, diarrhoea, wound
laceration, stroke, asthma, appendicitis, fever, DHF, head injury, GE (Gastroenteritis), ulcer,
CVA (Cerebrovascular Accident), DHF, vomiting, colic abdomen, and gastritis.
Level of training experiences, working experiences, triage knowledge and triage skills
During the past three years, all subjects had attended several short training courses.
The three most attended courses were the Basic Life Support (BLS) training course (100%), the
Basic Trauma Life Support (BTLS) training course (59.39%), the Advanced Life Support
(ACLS) training course (30.83%). In addition, some were trained about TOC (Triage Officer
Course), ambulance protocol, the Advanced Trauma Life Support (ATLS), ECG
resuscitation, Trauma Nursing Care (TNC), but less number of nurses was trained in Emergency
Care, first aid in emergency, and disaster management. By training index calculation, 66.2% of
subjects had training experience at a low level (1 - 5), 28.6% had training experience at a
moderate level (6 - 10), and only 5.2% had training experience at a high level (> 10). More than
half of subjects (51.90%) had experienced in working at ED more than five years, but most of
them (82.30%) had working experience in triage room less than five years. Currently, there were
only 16.20% have been working in triage room (Table 1).

Table 1
Frequency and Percentage of Subjects Classified by Experiences (N=266)
Experiences Frequency Percentage
Training experience (more than one

answer) BLS (Basic Life Support) 266 100.00
BTLS (Basic Trauma Life Support) 158 59.39
ACLS (Advanced Cardiac Life Support) 82 30.83
TOC (Triage Officer Course) 78 29.32
Ambulance protocol 39 14.66
ATLS (Advanced Trauma Life Support) 34 12.78
ECG Resuscitation 27 10.15
TNC (Trauma Nursing Care) 23 8.64
Emergency care 8 3.00
First Aid in Emergency 8 3.00
Disaster management 7 2.63
Training index
Index of training 1-5 176 66.20
Index of training 6-10 76 28.60
14 5.20
Index of training > 10
Working experience in ED
128
6-60 months 48.10
138
> 60 months 51.90
Working experience in triage
room 6-60 months 219
82.30
> 60 months 47 17.70
Current working in triage room
Yes 43 16.20
No 223 83.80
Level of triage knowledge and triage skills
The subjects reported a low level of triage knowledge and a moderate level of perceived triage skills
(see Table 2).
Table 2 Range, Mean, Standard Deviation, and Level of Triage Knowledge and Triage Skill score
(N=266)
Variables Possible range Actual range Mean SD Level

Triage knowledge 0-100 23-83 55.26 13.16 Low
Triage skill 5-100 49-99 75.12 11.23 Moderate
Rapid assessment 5-100 45-99 74.99 11.25 Moderate
Patient categorization 5-100 30-100 74.72 13.23 Moderate
Patient allocation 5-100 43-100 75.17 13.35 Moderate

Relationships between triage knowledge, training, and working experiences, and triage skills
The relationships between the mean scores of triage knowledge, training, and
working experiences and triage skills were examined using Pearson’s Product Moment
Correlation. The results showed the significantly positive relationships between triage skill
and triage knowledge (r = .38, p < .01), and working experience (r = .27, p < .01), training
experience (r = .37, p < .01) respectively (Hubungan antara skor rata-rata pengetahuan
triase, pelatihan, dan pengalaman kerja dan keterampilan triase diperiksa menggunakan
Korelasi Product Moment Pearson. Hasil penelitian menunjukkan hubungan positif yang
signifikan antara keterampilan triase dan pengetahuan triase (r = .38, p < .01), dan
pengalaman kerja (r = .27, p < .01), pengalaman pelatihan (r = .37, p < .01) masing-masing.
Discussion
The findings revealed that the mean score of triage skill and its sub-dimensions were
at a moderate level. This may be because that emergency nurses had more experience, and
82.30% of them had worked in triage room. In addition, the triage skill in triage room is similar
to primary assessment by ABC. During data collection, the researcher had met ED head
nurse and discuss about the role of emergency nurse in triage room. The majority of
emergency nurses have performed triage process collaborated with a physician that may
help nurses to have a triage skill for precise decisions at some circumstance. This is similar to
Chung (2005) who found that emergency nurses who had at least one year experience
would have triage skill (Temuan menunjukkan bahwa skor rata-rata keterampilan triase
dan subdimensinya berada pada tingkat sedang. Hal ini mungkin karena perawat gawat
darurat memiliki pengalaman yang lebih banyak, dan 82,30% diantaranya pernah bekerja
di ruang triase. Selain itu, keterampilan triase di ruang triase mirip dengan penilaian
utama oleh ABC. Selama pengumpulan data, peneliti telah bertemu dengan kepala
perawat UGD dan berdiskusi tentang peran perawat darurat di ruang triase. Sebagian
besar perawat gawat darurat telah melakukan proses triase bekerja sama dengan dokter
yang dapat membantu perawat untuk memiliki keterampilan triase untuk keputusan yang
tepat pada keadaan tertentu. Hal ini senada dengan Chung (2005) yang menemukan
bahwa perawat gawat darurat yang memiliki pengalaman minimal satu tahun akan
memiliki keterampilan triase. ). However, the subjects had less training in emergency care
especially triage training (29.32%) which may facilitate them to have a skill in a
moderate level. Similarly to a previous study that the perceived self-assessed competence
of nurses working in emergency setting were at a moderate level (Salonen, Kaunonen, Meretoja,
& Tarkka, 2007). In addition, all skills related to advanced nursing skill were not high
such as insertion of oropharyngeal or nasopharyngeal airway, assessment of internal and
external bleeding, stop bleeding, manual ventilation, and bag-valve-mask ventilations
(Namun subjek kurang mendapatkan pelatihan dalam perawatan kegawatdaruratan
khususnya pelatihan triase (29,32%) yang dapat memfasilitasi mereka untuk memiliki
keterampilan dalam tingkat sedang. Demikian pula dengan penelitian sebelumnya bahwa
kompetensi penilaian diri perawat yang bekerja di ruang gawat darurat berada pada
tingkat sedang (Salonen, Kaunonen, Meretoja, & Tarkka, 2007). Selain itu, semua
keterampilan yang berhubungan dengan keterampilan keperawatan tingkat lanjut tidak
tinggi seperti pemasangan orofaringeal atau nasofaring, penilaian perdarahan internal dan
eksternal, penghentian perdarahan, ventilasi manual, dan ventilasi bag-valve-mask. )

These skills were mainly performed by physician rather than nurses and most of prepared
ED nurses completed the degree at diploma level. In addition, existing training courses
did not include either advanced skill or drills for actual practice at hospital.
Congruent with previous studies (Cone, 2000; Ferrario, 2003; Salonen et al., 2007;
Anderson et al., 2006), working experience was correlated with triage skills (r = .27, p
=.001) particularly for those who continued working at ED more than five years, and those
experienced emergency nurses had more abilities in triage skill than novice nurses. Moreover, it
was similar to Hicks, Merritt, and Elstain (2003) who found that more years of experience
increased the decision-making consistency in triage skill (r = .42, p =.004) (Kongruen dengan
penelitian sebelumnya (Cone, 2000; Ferrario, 2003; Salonen et al., 2007; Anderson et al.,
2006), pengalaman kerja berkorelasi dengan keterampilan triase (r = .27, p
=.001) terutama bagi mereka yang terus bekerja di UGD lebih dari lima tahun, dan
perawat gawat darurat yang berpengalaman memiliki kemampuan lebih dalam
keterampilan triase daripada perawat pemula. Selain itu, serupa dengan Hicks, Merritt,
dan Elstain (2003) yang menemukan bahwa lebih banyak tahun pengalaman
meningkatkan konsistensi pengambilan keputusan dalam keterampilan triase (r = .42, p
=.004). ). In contrast, Considine et al. (2007) reviewed four studies which found that there was
no significant relationship between experience and triage decision making in triage skill. The
more experienced and less experienced emergency nurses could have the same ability to perform
triage. This may be due to other related factors such as training experience.
Training experience had a positive relationship with triage skill which reflects that the
more trainings or drills attended, the higher skill nurses develop. Consistency to a study
by Forsgren, Forsman, and Carlstrom (2009) who suggested that the regular training of
triage could improve skill of nurses to handle stressful work situation. In addition, the
mean score of triage knowledge which similar to previous study (Jezewski & Feng, 2007)
was at low level. The reason might be that almost emergency nurses in this study graduated in
diploma level, and a few had attended training course special to triage knowledge, and
only 16.20 % of subjects currently work in triage room. However, triage knowledge had a
positive relationship with triage skill even though it was a low level. This means that if triage
knowledge is high, the triage skill would also be high. This finding was congruent with a

previous study by Considine et al. (2007) who reviewed four studies to examine the effect of
factual knowledge on triage decisions. It was found that the factual knowledge had relationship
with triage decisions in triage skill. Moreover, there were relationship between knowledge,
skill, and judgment in nursing practice (Evans & Donelly, 2006). In addition, the
relationship between decision making, knowledge, and intuition with clinical experiences
were found in other study (Smith and Cone, 2010). However, the accuracy of triage decisions
and triage knowledge must be further explored as it might not have any relationship in some
particular context (Considine et al., 2007).
Since many subjects in this study graduated in diploma level, and less numbers had
attended training or specific course to triage, their triage knowledge were low. In addition, the
finding revealed that only 16.20 % of subjects currently work in triage room. It indicates
that nurses’ triage skills may be insufficient as a result of knowledge deficits. This
suggests that triage knowledge should be provided and included as in-service education for
ED nurses.
Conclusions, Limitations and Recommendations

The findings provide a better understanding of triage skill among emergency
nurses in East Java Province, Indonesia. The triage skill was found to be at a moderate level
while the triage knowledge was at a low level. In addition, there were significantly positive
relationship between triage skill and triage knowledge, training experience and working
experience (Temuan ini memberikan pemahaman yang lebih baik tentang keterampilan
triase di antara perawat darurat di Provinsi Jawa Timur, Indonesia. Keterampilan triase
ditemukan pada tingkat sedang sedangkan pengetahuan triase berada pada tingkat
rendah. Selain itu, terdapat hubungan positif yang signifikan antara keterampilan triase
dengan pengetahuan triase, pengalaman pelatihan dan pengalaman kerja. ). This could

serve as the basis of development of in-service education and training programs that emphasized
the specific triage knowledge for improving better skills. This study had a limitation in terms of
convenience sampling used and conducted in an urban area which limits generalizability of
findings. The findings suggest that the emergency nurses are required the proper knowledge
and experience to increase their triage skill (Ini dapat menjadi dasar pengembangan
program pendidikan dan pelatihan dalam jabatan yang menekankan pada pengetahuan
triase khusus untuk meningkatkan keterampilan yang lebih baik. Penelitian ini memiliki
keterbatasan dalam hal convenience sampling yang digunakan dan dilakukan di daerah
perkotaan yang membatasi generalisasi temuan. Temuan menunjukkan bahwa perawat
darurat diperlukan pengetahuan dan pengalaman yang tepat untuk meningkatkan
keterampilan triase mereka ). The necessity to

improve quality of care and patient safety, triage skill of the ED nurses must be offered as
continuing nursing education. Although it was a cross sectional study and limited
generalizability, a longitudinal study should be conducted and included the nurses in private
hospital.
Acknowledgements
I wish to gratefully thank to Faculty of Nursing, Prince of Songkla University for
funding support. Specially thank is also to Faculty of Medicine Brawijaya University, Director of
four hospitals in East Java and emergency nurses for their co-operation and facilitation during
the process of data collection.
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Relationships between Triage Knowledge, Training, Working

Experiences and Triage Skills among Emergency Nurses in East Java,

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 1

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 2

Emergency department (ED) generally provides immediate care 24 hours

everyday. The unpredictable numbers of patients coming to ED suffer from various

untuk menyelamatkan nyawa mereka.)However, the over crowdedness of patients visiting

UGD menerima perawatan yang tepat.)

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 3

emergency nurses is more focused as it is included the procedures of rapid assessment,

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 4

where have high workload and demands of care particularly in Indonesia.

As an example in one of the famous General Hospital in East Java province,

baik di antara perawat darurat Indonesia di masa depan.)

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 6

berikut: (1) penilaian cepat, (2) kategorisasi pasien, dan

berdasarkan literature review. )

allocation. It is measured by the Triage Knowledge Questionnaire (TKQ) developed based on

(TKQ) yang dikembangkan berdasarkan literature review.)

Working experience referred to the numbers of months in working as emergency

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 7

Research design and study framework

dengan menggunakan studi deskriptif korelasional untuk menguji hubungan antara

pengetahuan triase, pengalaman pelatihan, pengalaman kerja dan keterampilan triase.

includes rapid assessment, patient categorization, and patient

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 8

allocation (Keterampilan triase di UGD adalah kinerja perawat darurat menggunakan

physiology, pathophysiology, and common illness of the patients visiting to ED.

(Pengetahuan triase diperiksa dalam hal pengetahuan faktual dan pengetahuan

ke IGD. ) Procedural knowledge is a kind of knowing related to how to perform actions in

the patient, and providing emergency nursing intervention in ED

(Pengetahuan prosedural adalah jenis pengetahuan yang berkaitan dengan

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 9

digunakan dalam triase primer. Pengalaman pelatihan dapat meningkatkan keterampilan

memberikan intervensi keperawatan gawat darurat di IGD ) (Chung, 2005). To be skillful

konseptual penelitian ini. Faktor-faktor yang berhubungan dengan keterampilan triase

adalah tingkat pengetahuan triase, pengalaman pelatihan, dan pengalaman kerja. )

Figure: 1 Conceptual Framework of the Study

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 10

The sample and settings

The population were nurses working in ED in both tertiary and secondary

following reasons: 1) it provides public emergency services in East Java province as

pemerintah yang dipilih untuk penetapan target berdasarkan alasan berikut: 1)

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 11

belakang pendidikan keperawatan minimal diploma keperawatan. Dari 40 dari 306

pendidikan keperawatan di tingkat sekolah menengah atas) dikeluarkan. Dengan

demikian, 266 perawat gawat darurat memenuhi kriteria.)

and patient allocation. (Data dikumpulkan dengan menggunakan seperangkat kuesioner: 1)

triage skills, 60-80% =

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 12

menggunakan skala penilaian 1-5:

menjadi persentase. Dengan menggunakan acuan kriteria, skor berikut diinterpretasikan

< 60% = keterampilan triase tingkat rendah,

60-80% = keterampilan triase tingkat sedang, dan

> 80% = keterampilan triase tingkat tinggi;

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 13

sedang dan lebih dari 80% tingkat pengetahuan tinggi.)

experience. (Pengalaman pelatihan dalam tiga tahun terakhir diinterpretasikan

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 15

product moment correlation.

Sisanya (5,60%) telah menyelesaikan sarjana keperawatan. Tiga perempat subjek

Nurse Media Journal of Nursing, 3, 1, 2013, 511- 525 16