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Introduction: This research was designed to examine if there is a years of experience or CNPI mean score. The Kappa statistic
difference in nurse attitudes and experience for those who assign ranged from a high of 0.63 in the nurse participant with 1.00 to
Emergency Severity Index (ESI) scores accurately and those who do 1.99 years of experience to a low of 0.51 in the nurse participant
not assign ESI scores accurately. Studies that have used ESI scoring with 15 to 19 years of experience. The nurse participants with an
discussed the role of experience, but have not specifically addressed overall mean CNPI-23 score of 106 to 115 achieved the highest
how the amount of experience and attitude towards patients in agreement compared with a single participant with a CNPI-23
triage affect the triage nurse's decision-making capabilities. overall mean score of less than 77 who had a Kappa agreement of
Methods: A descriptive, exploratory study design was used.
0.50. The nurse participants with a CNPI-23 overall mean score
Data from 64 nurses and 1,644 triage events at 3 emergency between 81 and 92 demonstrated agreement of 0.54 to 0.60.
departments was collected. Participants completed demograph- Discussion: Based on the high level of liability the triage area
ic data, attitude (Caring Nurse Patient Interaction, CNPI-23) presents, special consideration needs to be made when deciding
survey, and triage data collection tools during the continuous 8- which nurse should be assigned to that area. The evidence
hour triage shift. Clinical nurse expert raters retrospectively produced from this study should provide some reassurance to ED
reviewed the charts and assigned an ESI score to be compared managers and nurses alike that nurses with minimal ED
with the nurse. Descriptive statistics were used to describe the experience and a working understanding of the ESI 5-level triage
nurse and Pearson's correlation was used to examine the algorithm possess the knowledge and the capacity to safely and
relationship between experience and attitude. appropriately triage patients in the emergency department.
Results: In this study of 64 nurse participants, the ESI score Key words: Emergency department; Triage nurse; Nurse
assigned by nurse participants did not differ significantly based on attitude; Nurse experience; ESI
demographic data and characteristics about the nurse make triage decisions based on case studies and 0.69 to 0.87
participant: age, sex, educational level, certifications, when nurses make triage decisions for actual patients. 9
employment status, shift status, years of nursing experience,
years of ED nursing experience, years of ED triage nursing
experience, and triage hours worked per week. Additionally,
each nurse was asked to rate their perceived competence Procedures
of triage ability: novice, beginner, intermediate, advanced,
or expert. The study was approved by the Institutional Review Board.
The CNPI-23, a 23-item instrument used to measure Exemption to full Institutional Review Board review was
caring attitudes and behaviors, was used in this study to granted because the study met all criteria for posing a low
reflect attitudes of nurses. The author’s permission was risk to participants. The study data were collected in 3
obtained to use this instrument. The CNPI-23 requires a phases. In phase I, ED nurses were briefed about the study
forced choice response on a 5-point Likert scale (1 = not at and invited to participate by the principal investigator (PI)
all to 5 = extremely). The instrument was scaled down from at education days. Nurse participants signed an informed
the original 70-item, 10-subscale instrument and produces consent at enrollment and were given the NCCT and
subscale scores in 4 distinct caring domains (clinical, CNPI-23 to complete.
relational, humanistic, and comfort care). The total CNPI- In phase II, enrolled nurse participants worked one
23 score range is 23–115. The instrument has been continuous 8-hour shift in the triage area. During this time
factor analyzed and tested and found to be reliable (clinical, they continued to use standard triage procedures to prioritize
r = 0.82 to 0.93; relational, r = 0.89 to 0.91; humanistic, patients and documented their triage assessments in the ED
r = 0.64 to 0.73; and comfort care, r = 0.61 to 0.74). electronic medical record. In addition, the participants
Attitude is defined as “a mental position with regard completed the Triage Case Tracking (TCT) form that
to a fact or state, or a feeling or emotion toward a fact or contained the patient medical record numbers, nurse-
state,” 10 whereas caring is defined as “to be concerned assigned ESI scores, and the number of resources the nurse
about, to feel interest or concern.” 13 The CNPI-23 and the predicted the patient would require. Completed TCT forms
subscales address Watson’s original theory of carative factors were placed in a locked box located in each study site’s triage
that embody both attitude and caring. These factors provide room. To thank them for their participation, the participants
clear guidelines for the nurse-patient interaction. The received a $25 gift card after completion of all requirements:
subscales are interdependent and reflect an individual NCCT, CNPI-23, and an 8-hour shift in triage.
nurse’s value system. Decision making in triage is guided In phase III, the completed TCT forms were collected
primarily by a categorized patient acuity algorithm but also by 1 of the 6 ESI-validated clinical expert nurse reviewers to
may be a factor of intrapersonal characteristics. 14 The obtain patient medical record numbers. Using the
linkage of patient outcomes with intrapersonal behaviors is emergency department’s electronic medical record, the
reflected in the CNPI-23. Items within the subscale of nurse experts carefully reviewed each patient’s medical
humanistic care refer to a nurse’s attitude and behaviors as record to determine if an accurate ESI score was assigned.
they relate to the patient’s own capacities and abilities. The clinical experts reviewed medical records on an
Relational care addresses the nurse’s respect of patient ongoing basis throughout the study implementation period
perceptions, and the clinical care subscale addresses the and recorded their findings on the triage research
clinical expertise. The comforting care subscale is most retrospective review forms.
representative of the hidden work associated with nursing. The ESI-validated clinical expert nurse reviewers were
The ESI is 5-tier algorithm used to categorize patient identified by ED clinical leadership as proficient in ESI
acuity based on key patient factors: presence of a condition scoring. The expert reviewers were educated on the
that is life threatening or high risk; vital signs; and how procedures for retrieving completed TCT forms, accessing
many resources the patient will need. The utilization of the the closed medical record, and completing triage research
validated and reliable ESI 5-tier triage scoring tool is best retrospective review forms and were briefed on the study
used in combination with patient presentation including intent by the PI. Additionally, they completed a refresher
age, history, pain, current medications, and patient severity ESI training module consisting of video case scenarios and a
of complaint to support an overall ESI score assignment. written test after completion. Using the posttest, the expert
The ESI has evolved during the past 14 years, and with use triage nurses’ interrater reliability was established by
of the Kappa statistic it has most recently demonstrated independent scoring on a minimum of 20 case scenarios
interrater reliability ranging from .70 to .80 when nurses and achieved 0.80 using Fleiss-Kappa statistics.
Enrollment
Attrition (n = 48)
Inability to complete 8-hour triage
assignment
Changed intent to participate
Voluntary Resignation
Analysis
Analyzed (n = 64)
Excluded from analysis due to missing > 10%
CNPI-23 data
No prior ED triage experience
ED Triage Experience
FIGURE 1
ED triage study participation. CNPI-23, Caring Nursing Patient Interactions-23 item; ED, emergency department; ESI, Emergency Severity Index; LVHN, Lehigh Valley
Health Network.
TABLE 1 Results
Demographic characteristics of registered nurses
Characteristic Frequency % The data from this study represent 64 nurse participants
triage cases
and 1644 patients triaged during the study period within
No. of RNs at site the 3 emergency departments. The rate of nurse
Site A: 36 979 59.5 participation (Figure 1) was 34.5% (64 of 185 eligible).
Site B: 7 121 7.4 The continuous 8-hour ED triage shift deterred some
Site C: 21 544 33.1 nurses from initially participating; 48 nurses dropped
Gender out after completing the required questionnaires because
Male 10 15.7 they were unable to fulfill the triage requirement, and 13
Female 54 84.3 nurses were excluded because they did not have the
ESI training course. Demographic data are shown in
Age (y)
(Table 1).
b 25 3 4.7
Participants were primarily women (84%) and ranged
26-35 19 30.0 in age from older than 25 years to 65 years (n = 61, with 3
36-45 13 20.3 nonrespondents); the 26 to 35 years and 36 to 45 years age
N 45 16 .25 groups together represented 42% of the nurses. A majority
No response 13 20.3 of the participants had an associate degree in nursing
Years of RN ED triage experience (44.0%). The ED experience ranged from 3 months to
.25-.99 6 9.4 35 years (M = 6.44, SD = 7.80), with the majority reporting
1.00-1.99 5 7.8 2 to 10 years experience (51.8%). Nurses who indicated
2-4.99 15 23.4 they had not completed the ESI training course were
5-9.99 14 22.0 eliminated from the primary study sample. The wide range
10-14.99 11 17.2 of experience contributed to the large standard deviations.
Nurse participants in the 3 emergency departments self-
N 15 13 20.3
rated their triage ability on a scale of 1 to 5 (novice,
Education
beginner, intermediate, advanced, and expert), with 80%
ADN 28 44.0 identifying as intermediate or advanced.
Diploma 12 19.0 The attitude scores for the study sample measured
BSN 22 34.4 by the CNPI-23 indicated an overall mean of 92.88 (SD =
No response 2 3.1 14.17). The CNPI-23 score stratified by experience
Employment status (Table 2) ranged from a low mean of 93.10 (N 20 years)
N 36 h/wk 49 76.5 to a high mean of 97.59 (1 to 2 years). The CNPI-23 overall
20-35 h/wk 4 6.3 mean score by site was lowest at site B (Table 3) (M = 91.37,
b 20 h/wk 3 4.7 SD = 6.59).
Weekend 3 4.7 In phase II of the study, 1644 ED patients were
No response 5 7.8 triaged by nurses and assigned an ESI score. Overall, the
agreement between the ESI-validated, clinical expert nurse
Triage ability (self-rate)
raters’ and the nurse participants’ ESI score assignment
Novice 5 7.8
using the weighted Kappa statistic was 0.65 (95%
Beginner 5 7.8 confidence interval [CI], 0.63 to 0.68). Four participants
Intermediate 19 30.0 had an interobserver agreement less than 0.20; of these, 2
Advanced 32 50.0 had more than 15 years of experience, one had 7 to 10
Expert 3 4.7 years of experience, and one had less than 2 years
of experience.
ADN, Associate’s degree in nursing; BSN, bachelor of science in nursing; ED, emergency
department; RN, registered nurse.
The assignment of ESI scores by experience level of the
nurse participants and ESI validated raters is described in
between experience and attitude. Additionally, one-way Table 4. The Kappa statistic ranged from a high of 0.63
analysis of variance was used to test for differences of attitude (95% CI 0.58 to 0.64, P b .001) in the nurse participant
across sites, gender, ESI agreement, and triage experience. with 1.00 to 1.99 years of experience to a low of 0.51 (95%
TABLE 2
Experience (Caring Nursing Patient Interactions-23 item scale and Kappa scores)
Years of experience
1-2 2.1-4.99 5-9.99 10-14.99 15-19.99 N 20
CNPI-23 total mean (SD) 97.59 (10.5) 93.37 (10.9) 93.53 (10.4) 96.79 (9.3) 95.06 (10.2) 93.10 (4.0)
Kappa by experience 0.630 0.59 0.632 0.61 0.51 0.631
CI 0.60, 0.66 0.49, 0.67 0.61, 0.66 0.47, 0.69 0.39, 0.63 0.62, 0.64
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 3
Site (Caring Nursing Patient Interactions-23 item scale and Kappa scores)
Site A Site B Site C
CNPI-23 total mean (SD) 94.97 (9.8) 91.37 (6.6) 96.95(10.7)
Kappa by site 0.56 0.45 0.60
CI 0.51, 0.67 0.42, 0.66 0.46, 0.75
CI, Confidence interval; CNPI-23, Caring Nursing Patient Interactions-23 item scale; SD, standard deviation.
TABLE 4
Years of ED triage experience and Emergency Severity Index score agreement with expert rater
RN ED triage experience (y) No. total cases Kappa (mean) CI
0.25-0.99 224 0.56 0.35, 0.67
1.00-1.99 321 0.63 0.60, 0.66
2-4.99 315 0.59 0.49, 0.67
5-9.99 261 0.63 0.61, 0.66
10-14.99 161 0.61 0.47, 0.69
N 15 314 0.51 0.39, 0.63
CI 0.39 to 0.63, P = .03) in the nurse participant with 15 to score of less than 77 who had a Kappa agreement of 0.50
19 years of experience. Substantial agreement (0.61 to 0.80, (P b .001). The nurse participants with a CNPI-23 overall
P b .001) was noted in 705 triaged patients, and 3.4% mean score between 81 and 92 (n = 54, 84%) demonstrated
(n = 56) were noted to have slight agreement (0.01 to 0.20). agreement of 0.54 to 0.60 (P b .001). CNPI-23 overall
Overall, 1260 cases (77%) had a range of 0.41 to 0.80, mean scores and Kappa agreement by site are displayed in
indicating moderate to substantial Kappa agreement Table 3.
between participants and the expert raters. Only 56 cases A one-way between subjects analysis of variance was
(3.4%) had slight agreement (less than 0.20). Site B conducted to compare the effect of ED triage experience
agreement was lowest, with 121 triaged patients (Kappa = on attitude (CNPI-23) at the P ≤ .05 level (F = 0.897,
0.45, 95% CI 0.38 to 0.52, P b .001). P = .49), the effect of gender on attitude (F = 0.017,
The nurse participants (n = 9) with an overall P = .90), or the effect of site of practice on attitude (F =
mean CNPI-23 score of 106 to 115 achieved the 0.216, P = .81). The years of experience in the emergency
highest agreement (Kappa = 0.71, P b .001) compared department and attitude scores were negatively correlated
with a single participant with a CNPI − 23 overall mean (r = − 0.78, P = .01).
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