triage decision making
novices’ decision making
experts’ decision making

How to Cite

Yuliandari, K. P. (2019). A LITERATURE REVIEW IN TRIAGE DECISION MAKING: SUPPORTING NOVICE NURSES IN DEVELOPING THEIR EXPERTISE. Belitung Nursing Journal, 5(1), 9–15. https://doi.org/10.33546/bnj.635
Share |


Emergency nurses often find themselves doing triage under time pressure and with only limited information, while the accuracy and rapidity of triage assessment may well determine a patient’s safety. A question may emerge as to whether novice nurses, who may have lack of experience and knowledge, could deal with such a demanding practice. Equipping novice nurses with important aspects in triage decision-making processes is pivotal. The aim of this literature review is to identify potential elements that could be utilised as supports for novice nurses in developing their expertise of making decision in triage. This study employed CINAHL, ScienceDirect, and PsycINFO to find relevant articles, using search terms “triage”, “decision-making”, “clinical decision-making”, combined with “expert”, and “novice”. The publication dates of those articles ranged from 1990 to 2015. 1487 articles was found and sorted based on inclusion and exclusion criteria, resulting in seventeen articles that had been used in this study. Literature review suggests four important elements for developing novices’ expertise in triage decision making: understanding the difference of novices’ and experts’ performance, critical analysis on theoretical approaches of clinical decision-making processes, defining factors that may influence nurses’ triage decision making, understanding errors that might be made by novices, and using appropriate learning strategies.


Supporting Agencies

School of Nursing Universitas Gadjah Mada, Indonesia


Copyright (c) 2019 Kurnia Putri Yuliandari

Creative Commons License

This work is licensed under a Creative Commons Attribution 4.0 International License.

Article Metrics

Abstract views: 3444 | PDF views: 1165


Download data is not yet available.

PlumX Metrics


Andersson, A. K., Omberg, M., & Svedlund, M. (2006). Triage in the emergency department–a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 11(3), 136-145.

Bakalis, N. A., & Watson, R. (2005). Nurses' decision-making in clinical practice. Nursing Standard, 19(23).

Benner, P. (1984). From novice to expert: excellence and power in clinical nursing practice. Menlo Park, California: Addison-Wesley Publishing Co.

Benner, P., & Tanner, C. (1987). Clinical judgment: how expert nurses use intuition. American Journal of Nursing 87(1), 23-31.

Cioffi, J. (1998). Decision making by emergency nurses in triage assessments. Accident and Emergency Nursing, 6(4), 184-191.

Cioffi, J. (1999). Triage decision making: educational strategies. Accident and emergency nursing, 7(2), 106-111.

Cone, K. J. (2000). The development and testing of an instrument to measure decision making in emergency department triage nurses. (Doctoral Dissertation), Saint Louis University, Missouri.

Considine, J., Botti, M., & Thomas, S. (2007). Do knowledge and experience have specific roles in triage decision‐making? Academic Emergency Medicine, 14(8), 722-726.

Croskerry. (2013a). From mindless to mindful practice—cognitive bias and clinical decision making. The New England Journal of Medicine, 368(26), 2445-2448.

Croskerry, P. (2006). Critical thinking and decisionmaking: avoiding the perils of thin-slicing. Annals of Emergency Medicine, 48(6), 720-722.

Croskerry, P. (2009). Context is everything or how could I have been that stupid. Healthc q, 12(Suppl), e171-s1763.

Croskerry, P. (2013b). From mindless to mindful practice—cognitive bias and clinical decision making. New England Journal of Medicine, 368(26), 2445-2448.

Croskerry, P., & Nimmo, G. (2011). Better clinical decision making and reducing diagnostic error. The Journal of the Royal College of Physicians of Edinburgh, 41(2), 155-162.

Dallaire, C., Poitras, J., Aubin, K., Lavoie, A., & Moore, L. (2012). Emergency department triage: do experienced nurses agree on triage scores? The Journal of Emergency Medicine, 42(6), 736-740.

Ebright, P. R., Urden, L., Patterson, E., & Chalko, B. (2004). Themes surrounding novice nurse near-miss and adverse-event situations. Journal of Nursing Administration, 34(11), 531-538.

Ek, B., & Svedlund, M. (2015). Registered nurses' experiences of their decision‐making at an Emergency Medical Dispatch Centre. The Journal of Clinical Nursing, 24(7-8), 1122-1131.

Elstein, A. S., & Schwarz, A. (2002). Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ, 324(7339), 729-732.

Epstein, R. M. (2013). Whole mind and shared mind in clinical decision-making. Patient Education and Counseling, 90(2), 200-206.

Fields, E., Claudio, D., Okudan, G. E., Smith, C. A., & Freivalds, A. (2009). Triage decision making: Discrepancies in assigning the emergency severity index. Paper presented at the IIE Annual Conference.

Fry, M., & Burr, G. (2002). Review of the triage literature: past, present, future? Australian Emergency Nursing Journal, 5(2), 33-38.

Gerdtz, M., & Bucknall, T. (1999). Why we do the things we do: applying clinical decision-making frameworks to triage practice. Accident and Emergency Nursing, 7(1), 50-57.

Gerdtz, M. F., & Bucknall, T. K. (2001). Triage nurses’ clinical decision making. An observational study of urgency assessment. Journal of Advanced Nursing, 35(4), 550-561.

Göransson, K. E., Ehnfors, M., Fonteyn, M. E., & Ehrenberg, A. (2008). Thinking strategies used by registered nurses during emergency department triage. Journal of Advanced Nursing, 61(2), 163-172.

Hoffman, K. A., Aitken, L. M., & Duffield, C. (2009). A comparison of novice and expert nurses’ cue collection during clinical decision-making: verbal protocol analysis. International Journal of Nursing Studies, 46(10), 1335-1344.

Innes, K., Plummer, V., & Considine, J. (2011). Nurses’ perceptions of their preparation for triage. Australasian Emergency Nursing Journal, 14(2), 81-86.

Marsden, J. (2008). Accident & emergency: Theory into practice (2nd ed.). New York: Bailliere Tindall.

Martins, A., Coelho, A. C., Vieira, M., Matos, M., & Pinto, M. L. (2012). Age and years in practice as factors associated with needlestick and sharps injuries among health care workers in a Portuguese hospital. Accident Analysis & Prevention, 47, 11-15.

Maule, A. J. (2001). Studying judgement: Some comments and suggestions for future research. Thinking & Reasoning, 7(1), 91-102.

Noon, A. J. (2014). The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum? International Emergency Nursing, 22(1), 40-46.

Paley, J. (2006). Evidence and expertise. Nursing Inquiry, 13(2), 82-93.

Parenti, N., Ghetti, G., Manfredi, R., Bagnaresi, A., Lanzoni, S., & Lenzi, T. (2006). 168: Quality Assessment of Nurse Triage: Which Factors Are Associated to Mistriage in Emergency Patients? Annals of Emergency Medicine, 48(4), 53.

Reay, G., & Rankin, J. A. (2013). The application of theory to triage decision-making. International Emergency Nursing, 21(2), 97-102.

Saintsing, D., Gibson, L. M., & Pennington, A. W. (2011). The novice nurse and clinical decision‐making: how to avoid errors. Journal of Nursing Management, 19(3), 354-359.

Salk, E. D., Schriger, D. L., Hubbell, K. A., & Schwartz, B. L. (1998). Effect of visual cues, vital signs, and protocols on triage: a prospective randomized crossover trial. Annals of Emergency Medicine, 32(6), 655-664.

Schubert, C. C., Denmark, T. K., Crandall, B., Grome, A., & Pappas, J. (2013). Characterizing novice-expert differences in macrocognition: an exploratory study of cognitive work in the emergency department. Annals of Emergency Medicine, 61(1), 96-109.

Smith, A. (2013). Using a theory to understand triage decision making. International Emergency Nursing, 21(2), 113-117.

Smith, A., Lollar, J., Mendenhall, J., Brown, H., Johnson, P., & Roberts, S. (2013). Use of multiple pedagogies to promote confidence in triage decision making: a pilot study. Journal of Emergency Nursing, 39(6), 660-666.

Spivak, M., Smith, A., & Cyntia Logsdon, M. (2011). Developing expert clinical nurses: grow them, hold them andlet them walk away. Journal of Nursing Management, 19(1), 92-97.

Standing, M. (2008). Clinical judgement and decision‐making in nursing–nine modes of practice in a revised cognitive continuum. Journal of Advanced Nursing, 62(1), 124-134.

Thompson, C., Dalgleish, L., Bucknall, T., Estabrooks, C., Hutchinson, A. M., Fraser, K., . . . Saunders, J. (2008). The effects of time pressure and experience on nurses' risk assessment decisions: a signal detection analysis. Nursing Research, 57(5), 302-311.

Thompson, C., & Dowding, D. (2002). Clinical ecision making and judgement in nursing. Edinburgh: Churchill Livingstone.

Walsh, C. (1991). Rapid decision making by emergency and coronary care nurses. ProQuest Dissertations Publishing.

Wolf, L. (2010). Acuity assignation: an ethnographic exploration of clinical decision making by emergency nurses at initial patient presentation. Advanced Emergency Nursing Journal, 32(3), 234-246.

Wolf, L. (2013). Research in triage?!?: using an integrated, ethically driven framework for clinical decision making. Journal of Emergency Nursing, 39(1), 104-106.