• Gudrun Reay, Lorraine Smith-MacDonald, Karen L Then, Marc Hall, and James A Rankin.
• Faculty of Nursing, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada. Electronic address: gudrun.reay2@ucalgary.ca.
• Int Emerg Nurs. 2020 Jan 1; 48: 100791.

IntroductionEmergency Department (ED) triage decision-making is a complex process. Triage scales are used to determine patient acuity level, however, they do not provide information on how nurses make triage decisions. This focus group study was part of a larger project to develop a psychometrically sound instrument to measure triage decision-making by nurses; the Triage Decision-Making Instrument. We report important incidental findings that emerged during the study that the participants identified as factors impeding triage decision-making.MethodsThree focus groups were conducted with 11 triage Registered Nurses. They commented on the instrument items and identified factors that influence triage decision-making. Transcripts were analyzed using thematic analysis.ResultsThree powerful inter-related themes emerged central to encumbering triage decision-making: competing systems (pre-hospital versus the ED), fluctuating patient volume resulting in 'intra-Canadian Triage and Acuity Scale' triaging, and personal capacity including experience and 'triage fatigue'.DiscussionThe findings demonstrate how interrelated system factors impede nurses triage decision-making. Triage nurses require support in their role and initiatives are needed to reduce the pressure they feel in relation to resolving system issues. Larger system issues and the capacity of the individual decision-makers must be accounted for within the context of increasing effectiveness and safety of ED triage.Copyright © 2019 Elsevier Ltd. All rights reserved.

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