Determinants influencing triage system at tertiary care centre as perceived by triage nurse: a qualitative study

Abstract

Objectives

The objective of this study is to explore the lived experiences of triage nurses.

Primary and secondary outcomes

The primary and secondary outcomes are the identification of barriers and facilitators that influence effective triage practice in a tertiary care centre in a low- and middle-income country.

Design

A qualitative phenomenological study was conducted, grounded in a realistic ontology, which assumes that reality is subjective and constructed through individual experiences. Semi-structured interviews were conducted with nursing staff until data saturation was achieved. Interviews were audio-recorded, transcribed, translated and analysed using Colaizzi’s phenomenological analysis method. Member checking ensured credibility.

Setting

The study was conducted in the triage unit of the emergency department at Patan Academy of Health Sciences, Nepal, where approximately 40 000 patients are served annually.

Participants

In-depth interview was conducted among the staff working in the triage unit. The study required nine in-depth interviews to attain saturation.

Results

Staff demonstrated a thorough understanding of the triage system and severity-based prioritisation tool used in triage. Training, protocols, teamwork and experience facilitated effective practice; however, resource limitations, overcrowding, staffing shortages, training gaps, communication challenges and social hierarchy adversely affected triage efficiency.

Conclusions

Triage is practised with conceptual understanding; however, performance is constrained by resource limitations, workforce insufficiencies, administrative and sociocultural challenges.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Depth of qualitative insights are derived from in-depth interviews and Colaizzi’s rigorous analytical framework.

• Data saturation is achieved and staff validation is done to enhance credibility.

• This study lacks differentiation based on varying levels of nursing experience despite inclusion of staff with heterogenous triage exposure.

• The study focuses on perception without evaluation of practical implementation of operational feasibility and cost implications.

• This is a single-centre study relying on the self-reported experiences.

Background

An effective emergency management system depends on efficient triage by triage staff. Triage is essential to managing patient flow, and timely identification of critically ill patients can reduce mortality.^{1 2} Triage nurses face several challenges such as limited triage spaces, high patient volumes, demand for non-emergency attendances and staffing shortages. A study from Saudi Arabia reported challenges related to managing critically sick patients, a lack of administrative support and the psychological burden on patients and their families.³ A study from South Africa highlighted the academic needs of nurses working in triage.⁴ Comparable challenges are evident in the triage of emergency departments in Nepal,^{5 6} where only 60% of primary and secondary hospitals have established triage.⁷ These challenges adversely affect the quality of the triage service. A systematic review and meta-analysis published in 2018 demonstrated reasonable validity across various triage systems; however, performance varied significantly. The key research question that emerged from this review concerned understanding of determinants influencing triage systems.⁸ Subsequent studies^{9 10} have largely focused on normative determinants including nurses’ experience and training, patient presentation and acuity, emergency department workload and shift conditions and cognitive and protocol-related factors. However, these studies predominantly explain what influences the triage system but offer limited insight into how these determinants interact and are experienced by triage nurses in their day-to-day practice, thereby constraining broader understanding of triage system’s behaviour. Therefore, this study was designed to explore the contextual determinants influencing the triage system in a low-resource setting through the lens of triage nurses.

Aims/objectives

The aim of this study was to explore lived experiences of triage nurses in order to better understand the contextual determinants influencing the triage system in a low-resource setting. The specific objective was to explain how triage nurses perceived barriers and facilitators that shape the effectiveness of triage at a tertiary care hospital in a low-resource setup.

Methods

This study employs a descriptive phenomenological design following Husserlian phenomenology.¹¹ The study aimed to explore the determinants influencing the triage system of a tertiary care centre, as perceived by triage nurses. This study is grounded in a realist ontology, which assumes that reality is subjective and constructed through individual experiences. The triage system is understood as a phenomenon shaped by the lived experiences of triage nurses. Knowledge is generated by carefully describing participants’ lived experience while the researcher suspends their own assumptions to understand the phenomenon as faithfully as possible. The researchers are value aware but value controlled; prior beliefs are minimised through ongoing reflexivity. The duration of research was from January to December 2025 and data collection was started from April 2025 after ethical approval and completed in September 2025.

Settings

The study was conducted at the triage unit of the Department of General Practice and Emergency Medicine at Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. The emergency department receives approximately 40 000 patients annually and provides 24-hour triage services.¹² PAHS is one of the first few hospitals in Nepal to establish a structured triage system, which has been operating as a team-based model for approximately ten years. Prior to this, triage was managed by a single individual rather than a structured system. Although triage exists in tertiary hospitals across Nepal, it commonly functions as a single staff-driven service rather than a systematic, team-based process. starting Triage system in Nepal.

The triage unit is a small station situated at the entrance of the emergency department. It is equipped with a computer system, a monitor with oxygen saturation probe, blood pressure cuff. One triage nurse is stationed per shift, with each shift lasting 6 hours. On patient ‘s arrival, the triage nurse assesses the patient, records the triage category in the computer system and transfers the patient to the emergency department. The patient categorised as red is immediately handed over to the emergency room staff. The triage protocol employed is WHO Interagency Integrated Triage Tool.¹³

As a tertiary care centre, the emergency department receives a diverse range of patients, including those in police custody and those presenting with violent behaviour. The patient load of the emergency department is directly proportional to the triage workload. A security guard is stationed at the entrance to the triage unit to manage crowding, and a small waiting area is located outside the unit. The hospital adopts a policy of providing emergency care to all patients presenting to the department; consequently, no patient is turned away without receiving treatment. Patient volumes are notably higher when outpatient departments are closed. Patient typically arrive at the triage unit in a state of anxiety and urgency. Culturally, patient do not want to wait when they come for emergency service, irrespective of triage category.

Participants selection, inclusion and exclusion criteria

Triage staff are registered nurses who rotate between the emergency department and the triage unit. They hold a minimum of 2 years of nursing education to be qualified as nursing practitioners and have between 2 and 5 years of clinical experience. The current staffing model assigns junior and intermediate level staff nurses to the triage unit, while senior staff nurses are deployed in critical areas within the emergency department.

At the outset of the study, it was estimated that 15 participants would be required to achieve data saturation, based on evidence from systematic reviews of qualitative studies.¹⁴ However, saturation was achieved after interviewing nine triage nurses. Saturation was defined as a point where no new ideas or themes emerged from data. Participants were recruited through convenience sampling. This approach was chosen because the eligible population was small and clearly bounded to nurses rostered to a single triage unit. This will make probability-based sampling impractical. The triage staff rotate through morning, evening and night shifts. We enrolled participants with at least 3 months of experience, which will provide the opportunity for the triage staff to get the experience of all shifts. Inclusion criteria comprised registered nurses holding a valid Nepal Nursing Council licence, currently working in triage who provided written informed consent. Staff who had not been posted to the triage unit within the preceding 3 months were excluded. For the purpose of this study, ‘Triage nurses’ refers to participants who met inclusion criteria and were enrolled in the study; ‘clinical experience’ was defined to include time spent specifically in triage duties, not general ward experience alone.

Data collection

Data were collected with semi-structured interviews. Participants were briefed individually about the study and provided with an information sheet both in Nepali and English (online supplemental file 1). Written informed consent was obtained from all participants prior to commencing the formal interview process. Interviews lasted approximately 30 min, were audio-recorded and supplemented by field notes documenting non-verbal cues and environmental factors. The interview guide (online supplemental file 2) comprised open-ended questions developed with expert input, including probes to explore the emotional, psychological and professional impacts of triage work. The validity of questions was ensured on discussion within the research team and social science experts. Questions that arose spontaneously during the interviews were also permitted. Interviews were recorded using the audio recorder function of mobile devices and subsequently transferred to a single password-protected computer, after which the recordings were deleted from the original device.

Data analysis

All interviews were transcribed and translated into English, and cross-checked against original Nepali content by two independent researchers. Participants reviewed the English transcripts to ensure accurate representation of their statements. Colaizzi’s¹⁵ phenomenological analysis method was employed, which involved repeated reading of transcripts, extraction of significant statements related to determinants influencing the triage system, formulation of meaning, clustering into themes and generation of a comprehensive description of the phenomenon. An iterative process was adopted whereby meanings were continuously compared across participants, moving repeatedly between original transcript, significant statements, emerging meanings and developing themes. Participant validation was conducted to confirm the credibility of the findings. Whenever uncertainty or disagreement arose regarding interpretation, the original transcript was revisited to ensure that emerging meaning aligns with the idea or perception of the participants. Data were entered into a Microsoft Excel sheet and were coded manually; analytical decisions and interpretations were made by the research team. Coding consistency was verified through independent double-coding of transcripts by two researchers. Discrepancies were resolved through discussion and iteratively refining the codebook until consensus was reached. Data source triangulation was achieved by comparing interview transcripts with field notes and audio recordings by two team members for each. Consensus discussions were held to strengthen the credibility of the interpreted themes.

Quality control

The researchers in this study are medical doctors, and their experience in emergency care may have influenced the research process. The professional background of researchers provided a strong understanding of the triage system, clinical workflow and contextual challenges, facilitating the design of relevant research questions. This may have enhanced the depth of contextual understanding. However, their clinical role may have introduced certain assumptions into the interpretive process. The relationship between researchers and staff may have facilitated rapport, openness and shared understanding of clinical language and experiences. This study acknowledges the role of researchers, their values, and reflexivity in the inquiry process. Researchers maintained individual reflexivity journals throughout data collection and analysis. These journals were revisited during analysis to ensure that interpretations reflected participants’ accounts rather than personal clinical assumptions.

To ensure trustworthiness, the study has followed established criteria. Credibility was ensured through member checking and iterative data analysis. Transferability was achieved by providing a thick, detailed description of the study setting, staff characteristics and contextual factors. Dependability was ensured through a structured interview guide and consistent data collection. Confirmability was ensured by reflexive journaling and an independent review of translation. Authenticity was addressed by ensuring that diverse experiences were accurately captured and reflected in the findings.

Results

Triage nurse characteristics

Nine interviews were conducted with participants to achieve data saturation. All participants were female, with a median age of 34 years, a minimum age of 25 years and a maximum age of 42 years (table 1). Their triage experience ranged from 1 to 5 years. Two participants had 2 years’ experience and a further two had 5 years’ experience, while five had experience between 3 and 4 years. To protect participant anonymity, the ages reported alongside individual quotations are presented as 5-year bands (21–25, 26–30, 31–35, 36–40 and 41–45 years).

Table 1. Triage nurse characteristics (n=9).

Variables	Frequency/percentage
Female	9 (100%)
Median age (years)	34
Minimum age (years)	25
Maximum age (years)	42
Age category
21–25	2
26–30	2
31–35	3
36–40	1
41–45	1

Understanding and practising triage prioritisation

Triage nurses demonstrated an understanding of triage as a tool for rapid assessment and prioritisation. They described triage as an essential first point of clinical contact for patients attending the emergency department: “we assess patients based on their presenting symptoms and categorize the level of urgency of their condition” (Female, 20–25 years). The decision to categorise was based on the patients’ conditions: “in difficult situations, we prioritize patients based on the severity of their injuries or illnesses” (Female, 26–30 years). Triage nurses were confident that the colour-coded system helped them prioritise care: “giving care based on priority is key (Paused) red should be treated within a minute” (Female, 20–25 years). Triage nurses also believed that their work in triage made urgency visible to treating doctors. Triage nurses also described the concept of re-triaging as necessary for patients’ safety: “sometimes, you reassess a green case if their condition worsens and triage them back to the red or yellow category, but this is usually done in the emergency by treating doctor,” (Female, 30–35 years). They emphasised that effective triage prevented treatment delays and improved flow in the emergency department: “patients receive the care they need on time and avoid delays in treatment, right time, right patient and right place, I believe this is what we are trying to achieve” (Female, 35–40 years), “patients will receive timely treatment and do not have to wait long, depending upon their severity, however sometimes green should wait to give priority to red category patients” (Female, 35–40 years). Many expressed pride in the effectiveness of triage, explaining that (Raised tone) “triaging helps us categorize patients and those needing urgent care are getting it” (Female, 40–45 years).

Facilitators of effective triage

Training, protocols and system preparedness

Triage nurses valued the training and orientation programmes which helped improve their competency. One triage nurse stated: “we undergo training programs that include real-life simulations like disaster drills and triage-specific exercises” (Female, 31–35 years). Triage nurses also mentioned that short orientation sessions by nursing staff (senior nurses and supervisors) helped improve triage accuracy: “the triage done before and the triage done after the orientation had many differences” (Female, 41–45 years). These short training sessions were conducted in a small group by nursing staff prior to participants’ first placement in the triage unit. Standardised protocols have also been helpful in improving triage nurses’ confidence and thereby enhancing system efficiency. One triage nurse requested curiously to add the following statement: “the current triage protocol here is a nationally implemented system. I have no problem with the protocol it’s good” (Female, 31–35 years). One triage nurse said she felt proud when staff from other hospitals come to observe and learn about triage. The triage nurse also acknowledged the importance of continuous learning for staying updated with changes in protocol, stating: “I believe that ongoing education and frequent training are very essential (Chuckel)” (Female, 36–40 years). Triage nurses stated that clear role allocation helped system preparedness and implementation: “We are allocated at triage, during this period, we do not have to take care of emergency patient, therefore, this compartmentalization of the role is practical and reliable” (Female, 31–35 years).

Professional growth, confidence, communication and team dynamics

Triage nurses described significant growth in confidence and skill through repeated real-world exposure. One triage nurse reflected: “I’ve become more systematic and confident with time and repeated practice” (Female, 41–45 years). Another triage nurse highlighted the importance of lived experience over theoretical knowledge alone, stating: “handling real patients in real-life triage scenarios is how we truly learn to manage them effectively,” (Female, 36–40 years). Communication and coordination were identified as a strong facilitator of confidence. Triage nurses described supportive team environments, stating: “our team communication is good, sometimes there are difficult patient, we communicate with doctors and seek help early” (Female, 21–25 years). Confidence, however, was described as dynamic and influenced by level of experience. Communication with patients and families was described as a critical component of triage. Triage nurses commonly used counselling to manage expectations, stating: “We communicate with our colleagues and patients, we have read that SBAR needs to used during communication, but we have not been able to follow strictly” (Female, 30–35 years). “Patients want them to be seen as quickly as possible, we manage these situations through counseling and explaining protocol” (Female, 30–35 years). One early-career participant shared: “it’s been one year now… the more I gain experience, I guess I will be able to manage triage more efficiently (Chuckle),” (Female, 21–25 years), while another acknowledged human limitation: “I feel confident 95% of the times but human beings are prone to human error” (Female, 31–35 years). Triage nurses felt that it would be helpful and learning if errors are pointed out, sometimes it goes unnoticed.

Barriers to effective triaging

Resource constraints and infrastructure challenges

Nurses consistently reported that limited resources and infrastructure hindered effective triage. Equipment shortages, malfunctioning devices and insufficient space were recurrent concerns. One participant noted: “No, we lack machines, (looked unsatisfied) and some break down, causing delays” (Female, 21–25 years). Another emphasised resource needs, highlighting the importance of equipment: “equipment… working equipment… and adequate triage nurses” (Female, 31–35 years). “The BP machine … sometimes they don’t work at all. I try to listen to BP and can’t hear anything. Then a doctor comes with their own equipment and they hear it fine. After all these years of taking BP… I feel like I don’t know how to take it, it is so embarrassing … makes us look incompetent” (Female, 31–35 years).

The impact of overcrowding and inadequate manpower was also frequently reported: “During high patient flow, it is difficult for one person to triage them all” (Female 30–35 years). The lack of dedicated space and seating in the triage area further compounded high patient flow: “During high traffic, there is no room to move, there is no privacy, toilet is nearby, visitor even wander around mistakenly…” (Female, 41–45 years). Participants also expressed frustration over the need to multitask between triage unit and emergency room: “we need to triage the patient and take the patient to the emergency room, look for the bed and sometimes when patient is very sick we put them on oxygen and monitor, so during that time, triage is vacant, when we come back, waiting patients are unsatisfied, sometimes pass comments…” (Female, 41–45 years). Triage nurses proposed several measures to improve triage efficiency, focusing on human resources, equipment, and workflow organisation. “Equipment, Policies, Human resources, Running green OPD in evening would be effective in reducing the crowd” (Female, 31–35 years). The phrase “We need policy…” was cited by many participants, however, on inquiring, when did they mean by ‘policy’, the participants were uncertain about which policy they were referring to. Key recommendations included assigning dedicated triage nurses, increasing the number of doctors, ensuring functional equipment, and reorganising patient flow: “I think assigning triage nurses and training them adequately would be effective” (Female, 31–35 years).

Workload, patient flow, and prioritisation challenges

High patient volumes and complex case presentations often affected prioritisation and workflow. Nurses described the difficulties of managing green, yellow and red cases simultaneously while ensuring timely assessment: “Yes, some patients expect to be seen quickly and don’t understand when we prioritize red cases, leading to aggression,” (Female, 41–45 years). Many triage nurses noted that physiological derangements or mental health conditions, such as mania or schizophrenia, further complicated patient assessment: “Not specifically, but with schizophrenia or mania cases, it’s hard to take vitals, (long breath), ”(Female 26–30 years). “We enter, counsel them, consult with a doctor, and manage accordingly” (Female, 41–45 years). The pressure of balancing multiple responsibilities was highlighted as a significant source of stress: “First I try to cool down, and if the situation is inevitable, I simply avoid the situation by giving handover to someone else and go out to freshen up” (Female, 36–40 years).

Training and competency needs

Although some triage nurses had received general emergency training, triage-specific instruction was frequently absent or inconsistent. Participants expressed a clear need for targeted, repeated training to maintain competency: “Not yet just what I’ve read in books and learned from senior nurses,” (Female, 26–30 years). “I think these kinds of training need to be conducted time and again and must include everyone who is assigned in triage area,” (Female, 41–45 years). Experience was also identified as a crucial factor in triage decision-making. Triage nurses recounted scenarios where seasoned nurses could detect subtle clinical signs that less experienced triage nurses might miss: “Even if the person in triage is new and trained, experience matters. So I think experienced ones should be in the triage area,” (Female, 41–45 years).

Perception of patient about ‘Emergency’

Effective communication with patients, particularly those who are aggressive or have misconceptions about urgency, emerged as an important coping strategy. Nurses emphasised verbal counselling and explanation of triage processes to manage expectations: “We politely talk to the patient. We counsel them that the ER is busy and it may take some time to address their patient” (Female, 41–45 years). Despite these efforts, triage nurses highlighted challenges in dealing with non-cooperative patients and the limitations of communication when resources are constrained: “Some don’t want to understand these things and are really aggressive and there is nothing we can do about such people,” (Female, 41–45 years).

Social hierarchy

Triage nurses also proposed system improvements, including better staffing and more medical oversight, with several participants emphasising that the presence of a doctor in a triage unit would enhance patient compliance and reduce overall workload. One triage nurse stated: “I think it will be effective if a doctor is assigned in the triage area… the whole process of triaging and case pending in the ER would be reduced” (Female, 36–40 years). Another proposed: “I’d implement a system where doctors and nurses jointly decide referrals to OPD,” (Female, 31–35 years). One triage nurse observed: “even one doctor at triage would help (paused) patients believe the doctor more than the nurses” (Female 31–35 years).” The presence of a doctor was repeatedly noted as enhancing patient compliance as: “OPD patients don’t always listen to nurses, but they will listen if a doctor explains” (Female, 36–40 years). “Patients just don’t trust us. I might spend 15–20 min trying to convince a patient that they need to go to out patient, but they won’t listen. As soon as a doctor says the same thing, they accept it immediately, maybe we also didn’t know how to counsel the patient”, (Female, 41–45 years).

Discussion

In this study, triage nurses viewed triage as an important component of the emergency care system, used to prioritised patients, manage patient flow, reduce delays and deliver timely care. Triage nurses stated that identifying the severity of the patient is an essential first step in emergency care to ensure patient safety. They also stated that a system of coding or labelling patient priority is essential in triage. Furthermore, the triage nurses also mentioned that there are barriers to an effective triage system that need to be overcome.

A study conducted among nurses in Iran identified lack of clinical competency in history taking, clinical examination and critical thinking as factors affecting clinical judgement at triage.¹⁶ In this study, the triage nurses pointed out the need to improve their communication competency with colleagues and patients. They were confident in history taking and examination; however, poor equipment led them to question their competency. Insufficient space and security were additional concerns. These challenges were compounded when triage staff lacked psychological capabilities to handle stress and lose control when triaging in crowded conditions.¹⁷ Difficulties in administrative flows were also seen in this study, with a single person handling triage and patient transfer in a congested space, thereby compromising privacy and safety.

Triage nurses need to continually strive to adapt to a pressure environment while considering each patient and the entire emergency department as a whole entity. This concept was described in a grounded study conducted in Calgary among registered nurses, where it was defined as ‘momentary fitting in a fluid environment’. Therefore, triage is not an isolated entity but a system that coordinates the complex interaction between medical emergency, human emotions and fluctuating patient volume. Managing this system extends beyond personal capacity, traits, motivation and enthusiasm. It is likely that an individual will experience ‘triage fatigue’.¹⁸ Moreover, triage nurses in this study stated that an experienced practitioner can identify subtle clinical findings that are crucial, which new triage nurses would probably miss. Therefore, experiential learning through daily clinical practice is important to achieve competency.

A descriptive study conducted in Turkey 2020 reported that inadequate triage training and limited knowledge of triage tools are contributing factors for slow triage decision making.¹⁹ Another study from Australia emphasised that nurse-related factors included education and cognitive approach.²⁰ A systematic review has also highlighted nurse traits, experience and knowledge as key barriers to an effective triage system.²¹ Similar findings were observed from studies conducted in India,²² China²³ and Nepal.^{7 13} In the present study, participants also stated that although they had their emergency training during their academic years, triage-specific training was either absent or inconsistent. Therefore, they believed that additional short or long trainings would enhance their capacity and confidence. Several studies suggest triage training as a remedy for these barriers.^{7 16 23} However, there is a lack of evidence on the overall impact of training triage nurses and its contribution to the improvement of triage systems.

Triage decision support tools, workflow designs, space, equipment and patient flow are other factors influencing the triage system.²⁰ Several studies including systematic reviews report that high patient volume leads to cognitive fatigue and longer triage times.^{6 7 21 22 24 25} A study conducted in London exploring factors affecting the flow of patient through triage reported that 67% of the time triage nurses were absent from triage due to patient escort duties within the department. Such distractions and workflow disruptions were identified as contributory factors, highlighting the importance of an effective workflow design.²⁶ These factors collectively result in under or over triage.²² In this study as well, barriers to a good triage system included lack of space, overcrowding at triage, inadequate equipment and patients with various mental conditions, which endangered the safety of triage nurses. Therefore, improving the triage system requires system development, including decision support tools,²³ improved workflow design to manage overcrowding, and better management of space and equipment.⁷ Besides, interdisciplinary communication and coordination^{6 27} are necessary, with triage nurses functioning as a team rather than individuals. A systematic review suggests that team triage, particularly involving a physician, is associated with shorter waiting times and length of stay, and a reduced number of patients leaving without being seen.²⁸ Moreover, there has been growing use of artificial intelligence (AI). A systematic review conducted in Jordan in 2025 highlighted that AI provides a promising solution by enhancing the accuracy, efficiency and consistency of triage decision-making processes. This presents a transformative opportunity to improve the triage system.²⁹

On synthesising the findings of this study, a triage should function as a unit or department or a system comprising 4Ss: Space, Staff, Stuff and System. This concept of preparedness for a surge in patient numbers whereby Space refers to location, physical layout, infrastructure and access; Staff refers to healthcare workers designated for the given space; Stuff refers to equipment, machines and services; System refers to scope of service, guidelines, policies and procedures.³⁰ These four dimensions are interrelated. Training should be developed focusing on space, stuff and system. Likewise, system is a function of space, staff and stuff. Patient entering triage may not have sufficient information about the triage system. They view triage nurses as the first point of contact, and are not able to analyse the multidimensionality of the triage system. A phenomenological study in South Africa exploring patient’s experience reported a lack of privacy, confidentiality and adequate human resources. Moreover, they reported feeling dissatisfied, neglected and emotionally distressed due to prolonged waiting times and lack of effective communication.²⁵

In this study, triage nurses perceived that patients had misconceptions about emergency care. Moreover, some patients were uncooperative, which limited communication with them. Nevertheless, the triage nurses strongly believed that patients trusted doctors more and that outcomes would improve if doctors communicated on their behalf. This phenomenon reflects that the philosophical concept of cure has been dominated by doctors and care by nurses for a long time.³¹ Studies have described the patriarchal nature of the relationship between the two professional groups.³² A grounded theory highlighted the dominant power position of doctors within the health profession.³³ One of the workplace terms that reflect the relationship between doctors and nurses is ‘Doctors Order’, whereby doctors issue orders and nursing staff carry them out. This relationship has a historical basis.³⁴ This construct is not only social but also administrative and institutional. This social construct positions doctors as more knowledgeable while placing expectations on nurses to be empowered in patient care. Empowerment requires not only improvement of knowledge but also social, philosophical and political perspectives. By and large, this is a change in belief and worldview. Therefore, in the present context, improving public awareness is the feasible and acceptable initial step towards strengthening triaging system.

Despite all barriers, the triage nurses were confident and satisfied. They reported that even short orientation sessions on triage helped improve their accuracy. The existing triage protocol and role allocation were valued as a strength of triage system. They valued the increased confidence, lived experiences in managing wide range of patients, effective communication and recognition of human limitations. They also emphasised the need for adequate staffing, space, equipment and clear policies. The phrase “We need policy” was mentioned by many triage nurses. This phenomenon can be interpreted through symbolic interactionism,³⁵ whereby individuals create and disseminate ideas through social interaction.

Limitations and strengths of the study

The study has several strengths, including the depth of qualitative insights, achievement of data saturation, use of Colaizzi’s rigorous analysis framework and triage nurses validation to enhance credibility. However, the single-centre design, reliance on self-reported experiences and use of convenience sampling may limit the generalisability of results. However, this study design reflects the fact that PAHS is among the few Nepali hospitals with a structured, team-based triage system; findings are therefore intended to offer a transferable insight rather than statistical generalisability. A thick description of the setting was provided to support judgement about transferability. This study did not explicitly differentiate the findings based on varying level of nursing experiences and age, despite the inclusion of triage nurses with heterogeneous triage experience. Previous adverse triage incidents can also be a confounding factor, but the triage system did not have such reporting systems, so it was not possible to identify such events, therefore it was not possible to exclude it. Furthermore, the study was not designed to assess feasibility or cost implications. Therefore, this study captures the perception of triage nurses, but it does not evaluate the practicality or implementation potential of the identified factors. Additional dimensions, particularly related to policy and organisational structure, require further exploration. Finally, as feasibility and cost implications were outside the scope of this study, research into these determinants remains an important area for future study in similar settings.

The findings carry important implications for emergency department leadership and health system planners. Strengthening triage-specific training, improving staffing models, investing in infrastructure and promoting interprofessional collaboration may contribute to triage accuracy, staff satisfaction and patient outcomes. Such system-level interventions are also likely to reduce treatment delays, enhance operational efficiency and strengthen patient trust in emergency care services.

Conclusion

The study findings are consistent with previous studies, identifying human resources, space, training, overcrowding and patient-related factors as barriers to an effective triage system. The identification of power structure as a barrier to effective triage represents an important finding of this study. This study also highlights the strong motivation, professional pride and lived experience shared by the triage nurse. Furthermore, these findings reflect a complex interplay of belief shaped by underlying worldview. Therefore, the determinants of effective triage should not be viewed as a single solid and fixed factor but rather as a dynamic and a fluid state. Most of the triage in Nepal are single-nurse based; this inquiry hopes to collect evidence to progress to team-based triage.

Data availability statement

Data are available in a public, open access repository. Data are available upon reasonable request.