Nurses’ decision-making in the Manchester Triage System

influencing factors and improvement strategies*

Authors

Keywords:

Triage, Nurses, Emergency Service, Hospital, Professional Training, Patient Safety

Abstract

Objective: To explore nurses’ perceptions of decision-making in the Manchester Triage System, including implications for patient safety and improvement strategies.

Method: A qualitative and exploratory study was conducted in an emergency department in northern Portugal. Convenience sampling included ten nurses with over two years of triage experience. Semi-structured interviews were performed in May 2025 and analysed using Bardin’s content analysis.

Results: Triage was perceived as an essential contributor to patient safety by prioritising complaints and defining appropriate waiting times. Decision-making was influenced by nurse-related factors, patient-related factors, triage system limitations, and organisational context. Suggested improvements included audits, protocol revision, structured pain assessment, integration of early warning scores, ongoing training/recertification, mentorship, better information system interoperability, and institutional measures to reduce interruptions.

Conclusion: Triage decision-making is multifactorial and requires continuous professional development and organizational support.

Author Biographies

Nuno Alexandre Ribeiro Ferreira da Silva, Tâmega e Sousa Local Health Unit, Medical-Surgical Emergency Department, Penafiel, Portugal.

Nurse. Master's student in Medical-Surgical Nursing. Tâmega e Sousa Local Health Unit, Medical-Surgical Emergency Department, Penafiel, Portugal.

Cátia Daniela Macieira Salgado, Tâmega e Sousa Local Health Unit, Functional Unit IV, Penafiel, Portugal.

Nurse. Master's student in Medical-Surgical Nursing. Tâmega e Sousa Local Health Unit, Functional Unit IV, Penafiel, Portugal.

Enfermeiro Luís Carlos, Alto Ave Local Health Unit, Portugal.

Specialist Nurse. Master in Medical-Surgical Nursing. Alto Ave Local Health Unit, Portugal.

Enfermeiro Gestor Rui Campos, National Institute of Medical Emergency, Porto, Portugal.

Nurse. Master in Disaster Medicine. National Institute of Medical Emergency, Porto, Portugal.

Professor Mestre Tiago Alves, University of Porto, Portugal.

Nurse. PhD candidate in Nursing Sciences at the Abel Salazar Institute of Biomedical Sciences, University of Porto, Portugal.

Professor Filipe Fernandes, Polytechnic Institute of Health of the North, Portugal

Nurse. Polytechnic Institute of Health of the North, Department of Health Sciences, Vila Nova de Famalicão, Portugal.

Professora Doutora Isabel Araújo, University of Porto, Portugal.

Nurse. PhD in Nursing Sciences from the Abel Salazar Institute of Biomedical Sciences, University of Porto, Portugal.

References

1. Sartini M, Carbone A, Demartini A, Giribone L, Oliva M, Spagnolo AM, et al. Overcrowding in emergency department: causes, consequences, and solutions - a narrative review. Healthcare [Internet]. 2022 [cited 2025 Jul 16];10(9):1625. Available from: https://doi.org/10.3390/healthcare10091625

2. Azeredo TRM, Guedes HM, de Almeida RAR, Chianca TCM, Martins JCA. Efficacy of the manchester triage system: a systematic review. Int Emerg Nurs [Internet]. 2015 [cited 2025 Jul 16];23(2):47-52. Available from: https://doi.org/10.1016/j.ienj.2014.06.001

3. Grupo Português de Triagem. O Sistema de Triagem de Manchester e as vias verdes: princípios aplicáveis, integração e compatibilização de metodologias de trabalho [Internet]. Lisboa: Hospital Amadora Sintra; 2011 [cited 2025 Jul 16]. 9 p. Available from: https://www.grupoportuguestriagem.pt/wp-content/uploads/2021/02/Documentacao-Triagem-Manchester-e-as-Vias-Verdes.pdf

4. Cicolo EA, Ayache Nishi F, Ciqueto Peres HH, da Cruz DALM. Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review protocol. JBI Database System Rev Implement Rep [Internet]. 2017 [cited 2025 Jul 16];15(4):889-98. Available from: https://doi.org/10.11124/jbisrir-2016-003119

5. Fekonja Z, Kmetec S, Fekonja U, Reljić NM, Pajnkihar M, Strnad M. Factors contributing to patient safety during triage process in the emergency department: asystematic review. J Clin Nurs [Internet]. 2023 [cited 2025 Jul 16];32(17-18):5461-77. Available from: https://doi.org/10.1111/jocn.16622

6. da Costa FAD, Torres RS, de Sousa CPF. Manchester Triage: Nurses’ perceptions of its contributions and influencing factors. Rev Enferm Ref [Internet]. 2022 [cited 2025 Jul 16];6(1):e21028. Available from: https://doi.org/10.12707/rv21028

7. Gorick H, McGee M, Wilson G, Williams E, Patel J, Zonato A, et al. Understanding triage assessment of acuity by emergency nurses at initial adult patient presentation: A qualitative systematic review. Int Emerg Nurs [Internet]. 2023 [cited 2025 Jul 16];71:101334. Available from: https://doi.org/10.1016/j.ienj.2023.101334

8. Vilelas J. Investigação: o processo de construção do conhecimento. 4th. Lisboa: Edições Sílabo, Lda; 2025. 584p

9. Serviço Nacional de Saúde (SNS). Atendimentos por tipo de urgência hospitalar. [Internet]. Lisboa: SNS; 2025 [cited 2025 Jun 26]. Available from: https://transparencia.sns.gov.pt/explore/dataset/atendimentos-por-tipo-de-urgencia-hospitalar-link/table/?sort=tempo

10. World Medical Association. World Medical Association Declaration of Helsinki. JAMA [Internet]. 2013 [cited 2025 Jul 16];310(20):2191. Available from: https://doi.org/10.1001/jama.2013.281053

11. Bardin L. Analise de Conteúdo. 4th. Coimbra: Edições 70; 2024. 288p

12. Essa CD, Victor G, Khan SF, Ally H, Khan AS. Cognitive biases regarding utilization of emergency severity index among emergency nurses. Am J Emerg Med [Internet]. 2023 [cited 2025 Jul 16];73:63-8. Available from: https://doi.org/10.1016/j.ajem.2023.08.021

13. Jeong G, Lee H. Influence of emergency department nurses’ grit, Self-Leadership, and communication on their triage competencies: a descriptive survey study. Korean J Adult Nurs [Internet]. 2023 [cited 2025 Jul 16];35(4):356-66. Available from: https://doi.org/10.7475/kjan.2023.35.4.356

14. Gorick H. Factors that affect nurses’ triage decisions in the emergency department: a literature review. J Emerg Nurs [Internet]. 2022 [cited 2025 Jul 16];30(3):14-9. Available from: https://pubmed.ncbi.nlm.nih.gov/35224917/

15. Ordem dos Enfermeiros. Parecer do Conselho de Enfermagem e Mesa do Colégio da Especialidade de Enfermagem Médico-Cirúrgica N.o 04/2021 [Internet]. 2021 [cited 2025 Jul 12]. Available from: https://www.ordemenfermeiros.pt/media/21432/parecer-n%C2%BA-04_ce-e-mceemc-fun%C3%A7%C3%B5es-enfermeiros-siv-e-sub.pdf

16. Saban M, Zaretsky L, Patito H, Salama R, Darawsha A. Round-off decision-making: why do triage nurses assign STEMI patients with an average priority? Int Emerg Nurs [Internet]. 2019 [cited 2025 Jul 16];43:34-9. Available from: https://doi.org/10.1016/j.ienj.2018.07.001

17. Ku NWK, Cheng MT, Liew CQ, Chen YC, Sung CW, Ko CH, et al. Prospective study of pain and patient outcomes in the emergency department: a tale of two pain assessment methods. Scand. J Trauma Resusc Emerg Med [Internet]. 2023 [cited 2025 Jul 16];31:56. Available from: https://doi.org/10.1186/s13049-023-01130-9

18. Nakhleh A, Shehadeh N. Hypoglycemia in diabetes: An update on pathophysiology, treatment, and prevention. World J Diabetes [Internet]. 2021 [cited 2025 Jul 16];12(12):2036-49. Available from: https://doi.org/10.4239/wjd.v12.i12.2036

19. Nicolò A, Massaroni C, Schena E, Sacchetti M. The importance of respiratory rate monitoring: from healthcare to sport and exercise. Sensors [Internet]. 2020 [cited 2025 Jul 16];20(21):6396. Available from: https://doi.org/10.3390/s20216396

20. Kashani K, Omer T, Shaw AD. The Intensivist’s perspective of shock, volume management, and hemodynamic monitoring. Clin J Am Soc Nephrol [Internet]. 2022 [cited 2025 Jul 16];17(5):706-16. Available from: https://doi.org/10.2215/cjn.14191021

21. Ausserhofer D, Zaboli A, Pfeifer N, Siller M, Turcato G. Performance of the Manchester Triage System in patients with dyspnoea: A retrospective observational study. International Emergency Nursing [Internet]. 2020 [cited 2025 Jul 16];53:100931. Available from: https://doi.org/10.1016/j.ienj.2020.100931

22. Yang J, Wan X, Yu P, Li X. Factors affecting the triage decision-making ability of emergency nurses in Northern China: A multi-center descriptive survey. Int Emerg Nurs [Internet]. 2023 [cited 2025 Jul 16];67:101264. Available from: https://doi.org/10.1016/j.ienj.2023.101264

23. Reay G, Smith-MacDonald L, Then KL, Hall M, Rankin JA. Triage emergency nurse decision-making: incidental findings from a focus group study. Int Emerg Nurs [Internet]. 2019 [cited 2025 Jul 16];48:100791. Available from: https://doi.org/10.1016/j.ienj.2019.100791

24. Suamchaiyaphum K, Jones AR, Markaki A. Triage accuracy of emergency nurses: an evidence-based review. Int Emerg Nurs [Internet]. 2024 [cited 2025 Jul 16];50(1):44-54. Available from: https://doi.org/10.1016/j.jen.2023.10.001

25. Johnson KD, Gillespie GL, Vance K. Effects of interruptions on triage process in emergency department. J Nurs Care Qual [Internet]. 2018 [cited 2025 Jul 16];33(4):375-81. Available from: https://doi.org/10.1097/ncq.0000000000000314

26. Ouellet S, Gallani MC, Fontaine G, Mercier É, Lapierre A, Severino F, et al. Strategies to improve the quality of nurse triage in emergency departments: A systematic review. J Nurs Care Qual [Internet]. 2025 [cited 2025 Jul 16];81:101639. Available from: https://doi.org/10.1016/j.ienj.2025.101639

27. Williams B. The National Early Warning Score: from concept to NHS implementation. J Clin Med [Internet]. 2022 [cited 2025 Jul 16];22(6):499-505. Available from: https://doi.org/10.7861/clinmed.2022-news-concept

28. Li E, Clarke J, Ashrafian H, Darzi A, Neves AL. The impact of electronic health record interoperability on safety and quality of care in high-income countries: systematic review. J Med Internet Res [Internet]. 2022 [cited 2025 Jul 16];24(9):e38144. Available from: https://doi.org/10.2196/38144

29. Sérgio MSSBB, de Carvalho ALRF, Pinto CMCB. Perception of portuguese nurses: clinical supervision and quality indicators in nursing care. Rev Bras Enferm [Internet]. 2023 [cited 2025 Jul 16];76(3):e20220656. Available from: https://doi.org/10.1590/0034-7167-2022-0656

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Published

2026-09-25

How to Cite

da Silva, N. A. R. F., Salgado, C. D. M., de Oliveira, L. C. N., Campos, R. A. V., Alves, T. R., Fernandes, J. F. F. A., & de Araújo, I. M. B. (2026). Nurses’ decision-making in the Manchester Triage System: influencing factors and improvement strategies*. Cogitare Enfermagem, 31. Retrieved from https://revistas.ufpr.br/cogitare/article/view/103221

Issue

Vol. 31 (2026)

Section

Original Articles

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Copyright (c) 2026 Nuno Alexandre Ribeiro Ferreira da Silva, Cátia Daniela Macieira Salgado, Luís Carlos Nogueira de Oliveira, Rui Alexandre Vieira Campos, Tiago Rafael Alves, Joaquim Filipe Ferreira Azevedo Fernandes, Isabel Maria Batista de Araújo

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