Development and psychometric assessment of the triage nurses’ professional capability questionnaire in the emergency department

Today, triage is an integral part of the emergency management in the hospitals in the clinical care systems, and is regarded as an index in evaluations of the emergency [1]. If, upon admittance, a patient is not triaged accurately and does not receive the necessary clinical care, even high-tech units and specialists’ efforts may not prove to be effective in helping the patient’s condition in the following hours or days [2]. The process of triage in the hospitals is unpredictable and complicated [3]. Triage nurses are likely to encounter the patients whose conditions are critical and quickly changing—obviously thus, they should possess the necessary professional capability to assess the patients’ conditions rapidly, determine the clinical priorities accurately, and make the right clinical decision in order to react properly to such quick changes [4]. Lack of the expected professional capability results in the triage nurses’ errors in prioritization of the patients’ needs, which, in turn, results in overcrowding in the triage unit, patients’ dissatisfaction, and in some cases, deterioration of the patients’ conditions [5]. Therefore, the evaluation of the nurses’ professional capability is essential to identify the areas which need to be improved, pinpointing the educational needs, ensuring the provision of optimum care, identifying the strengths and weaknesses of the educational programs, and professional development [6]. An accurate identification of the areas where the nurses need to improve their professional performance and detecting the nurses’ educational needs necessitates an assessment of their professional capability using the valid instruments [7]. Lack of the standardized tests has always been an issue in evaluating the triage in the hospitals [8]. A review and analysis of the results of the studies conducted in the field of professional capability confirms the inadequacy of knowledge with regard to evaluation of the triage nurses’ professional capability, attributing to the fact that the nurses’ experiences and perceptions have not been addressed adequately enough [9]. Professional capability is a broad concept and can be defined variously according to the context, individuals’ characteristics, situation, and perspective [10]. Therefore, a comprehensive definition of the triage nurses’ professional capability, classification of the components of their professional capability, and identification of its indices is the first step toward development of an instrument for evaluation of the triage nurses’ professional capability.

Experts in the development of the psychometric instruments believe that the contents of an instrument must be extracted directly from the target population of the instrument [11]. Accordingly, there is need for a qualitative approach to establish the concept of the professional capability and identify its dimensions and sub-dimensions. Qualitative studies contribute to the development of the clinical questionnaires by clarifying the concepts and providing the definitions and items [12].

There are not any standard instruments for evaluation of the triage nurses’ professional capability in the emergency departments of the hospitals, and the existing instruments only address the triage nurses’ knowledge. Professional capability is not limited to the professional knowledge and includes a variety of domains. Thus, the present study was performed to develop and assess the psychometric properties of an instrument for evaluation of the triage nurses’ professional capability in order to fill the gap in the current body of theoretical and practical knowledge. In the present study, an integrated research approach is used including a combination of the qualitative and quantitative approaches that can result in a better understanding regarding the subject in question,compensate for the shortcomings of the exclusively qualitative or quantitative approaches, increase the reliability and validity of the study results, and create a new outlook in the sciences [13]. Also, an integrated approach enables the researcher to collect more comprehensive evidence for the research subject and consequently, provide a practical answer to the research question [14].

On the other hand, as the objective of the present study is the development and assessment of the psychometric properties of an instrument for evaluation of the triage nurses’ professional capability, an exploratory sequential mixed methods design would be the most appropriate method to execute the project. Such a design can enable the researchers to establish a theoretical framework for identifying the dimensions of the complex and multi-dimensional concepts; it can also prove to be useful when the variables are unknown, there is no framework or guiding theory, the researcher aims to extend the findings to different populations, or the objective of research is development of an instrument [15].

In the first stage of the study, the concept of professional capability in the nurses was defined. According to the data collected from the unstructured and focus interviews with triage nurses and emergency room doctors as well as a review of the literature. Thus, according to the obtained definition, a capable triage nurse should not only possess the clinical competence, but also have psychological capabilities and be committed to his/her professional duties. Initially 85 possible items for the assessment tool were created from the qualitative data. Five further items were then included based on the literature review carried out for the development of the instrument. After several meetings and based on the comments of the experts, certain items were eliminated or merged and the number of the items was reduced to 43 items.

The present study was carried out to develop and subsequently evaluate the psychometric properties of a triage nurses’ professional capability questionnaire. The questionnaire addresses a wide range of the triage nurses’ professional capabilities in the three domains of clinical competence (20 items), psychological empowerment (six items), and professional commitment (nine items). An evaluation of the psychometric properties of the questionnaire proved it to possess the satisfactory face, content, and construct validity and reliability for measuring the professional capability in the triage nurses. Initially, the questionnaire consisted of 85 items, which number was later raised to 90 based on the results of the researchers’ review of literature. After several meetings of the research team members and following experts’ comments, similar items were either eliminated or merged and eventually the number of items was reduced to 43. Next, the results of quantitative content validity evaluation showed the impact score of two of the items to be below 1.5 and those items were eliminated. Thus, the number of items fell to 41. In the qualitative content validity evaluation of the questionnaire, 6 items were merged. At this point, 38 items were left. In the item analysis phase, the correlation coefficients of 6 items were between 0.75 and 0.92 and those items were, as the research team members agreed, merged. Ultimately, 35 items made it to the factor analysis phase. Based on the results of factor analysis, 3 factors could determine 59.96% of the variance of the triage nurses’ professional capability questionnaire. In the present study, to determine the factors of the questionnaire, the researchers applied exploratory factor analysis with initial Eigenvalues of above 1 and a minimum factor load of 0.4 for an item to stay. Thus, in this stage, none of the items was eliminated and the 35 items remained in the questionnaire. One of the major indexes of the present questionnaire in the domain of clinical competence is clinical judgment skills. From the participants’ point of view, considering the complicated and unpredictable nature of triage in emergency departments, clinical judgment is an essential skill in triage nurses and has an impact on their diagnosis of patients’ problems and clinical decision-making. In other studies, the questionnaires which evaluate triage nurses’ performance only address their knowledge and, occasionally, clinical skills and do not measure the nurses’ clinical judgment skills. This is one of the strengths of the present questionnaire over similar instruments. Another important index of the present questionnaire in the domain of clinical competence is teamwork skills. According to the participants, work in the triage units of emergency departments is unpredictable and at critical times when there is overcrowding in the units, triage nurses have to deal with a large number of patients. In such circumstances, if triage nurses are not skilled at teamwork, they cannot manage and organize matters properly and, due to anxiety and hastiness, may commit clinical errors. According to Buljac-Samardzic, et al. (2020), teamwork skills as an important component of emergency nurses’ clinical competency [29]. The instruments used in other studies mostly measure triage nurses’ knowledge and the important index of teamwork skills is ignored. One of the strengths of the present questionnaire is that it addresses more indexes. Emotional stability and resilience are another important index of the present questionnaire in the domain of psychological empowerment. The participants’ experiences show that triage nurses need to possess high resilience and emotional stability to be able to cope with difficult and stressful conditions. When patients and their companions enter an emergency department, they are experiencing high levels of tension and may behave aggressively toward triage nurses. Thus, the nurses should enjoy psychological empowerment, including being resilient and emotionally stable, to be able to remain patient, manage their emotions, and provide care in a peaceful and concentrated manner. According to Norouzinia, et al. (2020), emergency nurses must possess resilience and emotional stability so that they can effectively use their abilities and take effective clinical measures in the critical conditions of an emergency. Though such factors as fatigue due to work overload, lack of personnel, and stressful work conditions in emergency departments can adversely affect the performance of the emergency personnel, nurses who are resilient and emotionally stable can manage their emotions and anger [30]. Most studies of triage nurses focus on the knowledge and clinical skills of this group of care givers. However, according to the participants of the present study, in addition to knowledge and clinical skills, triage nurses must possess psychological empowerment. Another important domain of the present questionnaire is professional commitment, one of the major indexes of which, as pointed out by the participants, is observance of the principles of communication. The participants of the present study stated that introducing oneself to the patients and their companions, answering the questions of the patients and their companions patiently and sincerely, and treating the patients and their companions with respect are the core principles of communication. According to Molina-Mula (2020), following the principles of communication is essential to providing care and facilitates the process of nursing. The ability to establish an effective relationship lies at the heart of caring for patients. A review of the questionnaires used in other studies of triage nurses shows that they do not address this aspect of nursing. Thus, one of the strengths of the present questionnaire is that it measures a wide range of triage nurses’ abilities and personal qualities [31].

Investigating the knowledge and skills of triage nurses in a hospital in South Africa, Phukubye et al. (2019) studied 150 nurses. The results of their study showed that the triage nurses did not possess sufficient knowledge and skill. Phukubye et al. use a researcher-made questionnaire in their study. However, no information is given about the number of the items, the content validity of the questionnaire, or the manner of measuring the reliability of the questionnaire. The content validity of the questionnaire was not measured either, which is another weakness of their study. Also, in developing the items of the questionnaire, the researchers did not consider the experiences and perspectives of triage nurses and only relied on a review of literature. In contrast, 80% of the items of the present questionnaire were developed based on triage nurses’ opinions with a content analysis approach and 20% were based on a review of literature. It is likely that the development of items according to the views of the participants has increased the reliability of the results of determining triage nurses’ professional capability. This is another strength of the present study [32].

In a similar study, Duko et al. (2019) investigated the knowledge and skill of emergency nurses in triaging patients in a hospital in Ethiopia. They reported the knowledge and skill of the subjects to be low. Duko et al. used a researcher-made questionnaire which comprised of 17 questions on knowledge and 37 questions on skill. The content validity and construct validity of the questionnaire were not measured. The reliability of the questionnaire was verified with a Cronbach’s alpha of 0.91. The questions were designed based on a review of literature and nurses’ views (qualitative approach) were not considered. Moreover, their questionnaire evaluated only the knowledge and skill of the nurses and the other aspects of the professional competence of triage nurses were ignored [33].. The present questionnaire, however, was developed using a combination of a qualitative approach and a review of literature and the items address a wider range of triage nurses’ professional capabilities. Also, unlike other studies, the present study conducts a thorough assessment of the psychometric properties of the researcher-made questionnaire, which is one of the strengths of the study.

Haghigh et al., (2017) used a researcher-made questionnaire to assess the knowledge of the triage nurses in Iran. The content validity of the questionnaire was verified by 10 nursing professors. A Cronbach’s alpha of 0.70 confirmed the reliability of the questionnaire. The construct validity of the questionnaire was not measured. The questions were designed based on a review of literature and nurses’ views (qualitative approach) were not considered. Moreover, their questionnaire evaluated only the knowledge of the nurses and the other aspects of the professional capability of triage nurses were ignored [34].

Javadi et al., (2016) employed a researcher-made questionnaire to assess the professional knowledge and performance of the triage nurses in Iran. The questionnaire was consisted of 15 4-point items for measuring the knowledge and 10 4-point items for measuring the performance. The reliability of the instrument was verified with a Cronbach’s alpha of 0.87. The findings showed that triage nurses’ professional knowledge and performance are less than the satisfactory level. The content validity and construct validity of the questionnaire was not measured. The items in this instrument have been developed based on the library research and do not reflect the triage nurses’ perceptions [35].

Aloyec et al., (2014) employed a researcher-made instrument to assess the professional knowledge and performance of the triage nurses in a hospital in Tanzania. The skills section was consisted of 35 items and the knowledge section was consisted of 30 4-point items. The reliability of the instrument was tested using the test-retest method and was verified with a Cronbach’s alpha of 0.78. The findings showed that the professional knowledge and performance of the triage nurses are unsatisfactory. The content validity and construct validity of the questionnaire was not measured. The questions were designed based on a review of literature and nurses’ views (qualitative approach) were not considered [36].

Fathoni et al., (2013) used a researcher-made questionnaire to measure the professional knowledge and skills of the nurses in triaging the patients. The skills section was consisted of 37 items and the knowledge section was consisted of 15 items. The content validity of the questionnaire was confirmed by three experts. The reliability of the instrument was tested using the test-retest method and was verified with a Cronbach’s alpha of 0.95.They showed that the knowledge and skills of the triage nurses are unsatisfactory. Moreover, they recommended conducting further researches to develop a standard instrument for evaluation of the triage nurses’ capabilities. The content validity and construct validity of the questionnaire was not measured. Moreover, their questionnaire evaluated only the knowledge and skills of the triage nurses and the other aspects of the professional capability of triage nurses were ignored [37]. In the present study, the items of the questionnaire were developed according to triage nurses’ perspectives and experiences and an extensive review of literature to guarantee the relevance of the items (an inductive-deductive approach). In addition, all the psychometric properties of the designed instrument were tested. Thus, the present instrument more specifically addresses the professional capability of nurses. A reasonable number of items, ease of use, simple questions, and acceptable reliability and validity are the most important features of the present questionnaire which make it very practical.

As the hospital triage nurses work in a complicated and unpredictable environment, they are expected to enhance their professional capabilities in this regard, the nurse administrators are expected to conduct regular evaluations of the nurses’ capabilities using the standard instruments. The questionnaire developed in the present study was found to be a valid and reliable instrument for assessment of the various aspects of the triage nurses’ professional capabilities. Thus, the nurse administrators can employ this instrument to measure the triage nurses’ professional capabilities and take measures in order to enhance their professional capabilities by identifying their weaknesses, and, in turn, improving the quality and effectiveness of the triage.