RESEARCH

CAN EMERGENCY NURSES TRIAGE SKILLS BE

IMPROVED BY ONLINE LEARNING? RESULTS
OF AN EXPERIMENT
Authors: James A. Rankin, RN, ACNP, PhD, Karen L. Then, RN, CCN(C), ACNP, PhD, and Lynda Atack, RN, PhD,
Calgary, Alberta, and Toronto, Ontario, Canada
Introduction: Emergency nurses deal with increasing complexity of patients. In 2003 there were over 14 million ED visits
in Canada. The Canadian Triage and Acuity Scale (CTAS) is a 5level system used by ED triage nurses to classify patients. There
is a need for standardized training for all triage systems. In an
effort to improve access to CTAS training, a 6-week Web-based
CTAS workshop was developed. We determined the impact of
Web learning on the accuracy of the triage skills of registered
nurses (RNs).
Methods: An experimental method was used in which 132
RNs were randomized to an intervention group (n = 65) or
control group (n = 67). All RNs received exactly the same
content and learning activities. The experimental group differed
from the control group in 3 ways: a mandatory tutorial,
awarding of marks for online discussion, and completion of a

n the last decade emergency nurses have experienced

increasing patient complexity.1 The Canadian Triage
and Acuity Scale (CTAS) is a 5-level system (Table 1)
that is used to classify the severity of patients conditions.2
The CTAS is patient centered, accurate, and reliable for
rapid assessment and is the recommended triage tool for
Canadian emergency departments.3-5 Patients are classi-

James A. Rankin is Professor, Faculty of Nursing, University of Calgary,

Calgary, Alberta, Canada.
Karen L. Then is Professor, Faculty of Nursing, University of Calgary, Calgary,
Alberta, Canada.
Lynda Atack is Professor, Centennial College, Toronto, Ontario, Canada.
Funding for the research study was provided by the Office of Health and the
Information Highway, Health Canada. The online course development was
funded by The Change Foundation, Toronto, Ontario, Canada.
For correspondence, write: James A. Rankin, RN, ACNP, PhD, Faculty of
Nursing, University of Calgary, 2500 University Dr NW, Calgary, Alberta,
Canada T2N 1N4; E-mail: rankin@ucalgary.ca.
J Emerg Nurs 2013;39:20-6.
Available online 8 September 2011.
0099-1767/$36.00
Copyright 2013 Emergency Nurses Association. Published by Elsevier Inc.
All rights reserved.
http://dx.doi.org/10.1016/j.jen.2011.07.004

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JOURNAL OF EMERGENCY NURSING

workplace project. Data were collected using standard instruments, chart audit, and interviews.
Results: The Web course provided a standardized and effective
educational experience that enhanced emergency nurses triage
accuracy. The mandatory online tutorial, online discussion, and
workplace project increased the RNs preparation for online
learning, and these educational methods were successful in
transferring triage learning to practice.
Discussion: Web learning can help professionals maintain
competency and support professional practice. Further research is
needed to provide evidence for best practices in E-learning for
RNs. The accuracy of the RNs triage assessment impacts patient
health, hospital accreditation, and funding.
Key words: Online learning; Triage skills; CTAS

fied on an ordinal scale from level I (in need of resuscitation) to level V (nonurgent). Triage training tends to be
informal and focuses on documentation evaluation rather
than triage accuracy.6,7
Two research problems are the need for ongoing standardized training to develop triage skills and access to
timely delivery of educational content. Traditionally,
CTAS training in Canada has been offered as a day-long
workshop. Barriers such as staff shortages, shift work, and
budget constraints have reduced access to the course. In
addition, 1-day workshops have resulted in limited changes
in practice.8 In an effort to improve CTAS training, the
Ontario Hospital Association Change Foundation funded
the development of a 6-week Web-based CTAS workshop.
Learning takes place through text, case studies, and online
discussion moderated by a course facilitator.
The significance to nursing is to determine whether
Web-based learning impacts clinical practice. An extensive literature search of CINAHL (Cumulative Index to
Nursing and Allied Health Literature) and MEDLINE
(1997 to 2010) was conducted. Authors have described
advantages of Web-based learning including convenience, decreased costs, and accessibility for rural learners.9-12 Disadvantages include hardware costs, computer
skills, and the need for self-direction.13,14 Findings from

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TABLE 1

Overview of CTAS
CTAS level

CTAS descriptor

Level I: Resuscitation
Level II: Emergent

Condition threatens life or limb

Condition that is a potential
threat to life or limb
Condition that could progress to
a serious problem requiring
emergency intervention
Condition benefitting from
intervention or reassurance
within 1-2 h
Acute but nonurgent condition
or chronic condition with or
without deterioration; could be
referred elsewhere

Level III: Urgent

Level IV: Semiurgent

Level V: Nonurgent

earlier descriptive studies are useful; however, there is a

paucity of rigorous experimental research that explains
or predicts phenomena in distance learning.13,15 Practices
common in online courses that have yet to be tested
include an introductory online tutorial, awarding marks
for discussion, and structuring learning activities that link
to the workplace.
Investigators indicate that many registered nurses
(RNs) rank themselves at a beginner level with computer
and Internet skills. Several authors found that the majority
of RNs enrolled in a Masters program had no previous
computer course experience.16-18 The nurses overestimated
their computer skills and encountered problems once the
course was under way. Online tutorials have been used as
an adjunct to traditional learning.19,20 Unfortunately, not
all institutions provide an online orientation tutorial, and
no studies were identified where investigators specifically
examined this variable.
Allotting marks to encourage asynchronous discussion
is a widespread practice in online education.10,21-23 There
is a gap, however, in the evidence-based literature regarding
whether awarding marks to stimulate discussion is the best
practice for busy professionals.
Programs that are relevant to learners needs in the
workplace have a greater impact on learning.24 The need
for relevant content and assignments for workplace learners has also been identified.25-27 Other researchers have
made use of online resources to support practice in the
workplace for advanced practice nurses.28,29 However,
these studies did not relate to student workplace projects
per se. The general education literature clearly supports

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linking theory with practice; no studies were identified

regarding the impact of a workplace project, embedded
in an online course, on professional practice. Senior
health care decision makers are interested in measuring
the impact of online courses on clinical practice. Previous
authors have suggested that health providers apply their
learning and improve their practice after completing
Web-based courses. 17,30 More recently, investigators
found that an online learning resource facilitated collaborative practice among health professionals.31 These studies provide a useful research foundation but fall short of
identifying cause-and-effect relationships in online education. Objective measures are needed to assess the impact
that technology-assisted learning has on practice.13 We
conducted a pilot study with the first iteration of the
CTAS Web course.32 It was found that the RNs were
underprepared in terms of computer skills at the start
of the course, required online interactions to motivate
them and facilitate learning, and applied their online
learning to triage practice. On the basis of the review of
the literature and pilot study findings, we decided to conduct an experiment. The purpose of this study was to
determine the impact of 3 changes to the standard
Web course on clinical practice in the setting of CTAS
assessment. Three changes were incorporated into the
new course as described in the Design section. The
null hypothesis was as follows: There will be no difference
in satisfaction with Web-based learning and CTAS triage
accuracy between the RNs in the control (C) group compared with the RNs in the experimental (E) group.
Methods

DESIGN

An experimental design was used in which 132 RNs were

randomized to the E group (n = 65) or C group (n = 67).
All nurses in the course received exactly the same content
and learning activities in the weekly modules. The E group
differed in 3 ways: (1) they had a mandatory tutorial, (2)
25% of the grade was awarded for online discussion, and
(3) they conducted a triage workplace project. The workplace project involved either presenting an in-service session on CTAS to their colleagues or development of a
CTAS resource for the general patient population (eg, a
pamphlet or poster). In the C group, the tutorial was
recommended but not required, there were no marks for
online discussion, and there was no workplace project.
Data were collected on both groups by use of established
instruments: the Learner Demographic Survey (LDS) and
the Online Learner Support Instrument (OLSI).17 In addition, the RNs were interviewed about their experiences, a

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chart audit tool was used to evaluate changes in practice,

and their online discussion was audited.
SAMPLE AND SETTING

The sample was drawn from all nurses (N = 203) who

enrolled in the online CTAS course offered through Centennial College, Toronto, Ontario, Canada. They received
information regarding the purpose of the study and were
provided with an informed consent form. Of the 180
RNs who completed the course, 132 agreed to participate
in the study. A power analysis determined that a sample of
63 RNs was needed for each group to detect a difference if
one truly existed. Power analysis parameters included medium effect size (0.50), equal to .05, and power of 0.80.
Multistage sampling was used because we recognized that
nurses working at the same site would compare experiences
regarding their online course. Nurses were first identified
by work site, and then all nurses from a particular site were
randomly assigned to the E or C group. Ethical approval
was obtained from Centennial College and the participating clinical sites.
INSTRUMENTS

Two instruments were administered: the LDS and the

OLSI.17 The LDS was administered before the start of
the course. The LDS is a 21-item questionnaire that provides demographic information such as age, education
level, and Internet skills. The RNs experiences were measured at the end of the course with the OLSI. The OLSI is
a 52-item self-report instrument developed and used previously by us. Face validity and content validity were established by obtaining a mean congruency agreement among 5
reviewers of 89.9% (range, 77.7%-100%). Favorable internal consistency values have been previously reported for
each of the subscales ( ranged from .62 to .76).17 Learners experiences were measured on 5 subscales: interactions with teacher and peers, course design and resources,
technology, environment, and overall impressions. Respondents used a Likert scale ranging from 1 to 5 to rank their
responses, where 1 indicates strongly disagree and 5 indicates strongly agree. A section of the OLSI includes 6
self-report items that measure post-course computer skills
and triage application.
PROCEDURES AND DATA ANALYSIS

Six hospitals across Canada were randomly selected to

participate in the chart audit. A shift worked by a CTAS
graduate was randomly selected for audit. A total of 381
charts were returned and 367 were audited; 14 were discarded because the triage code was missing or illegible.
The chart audit was conducted by an emergency nurse
who is a CTAS expert and is a provincial auditor for

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triage evaluation. The auditor was blind to the nurses

participation in the C or E group. The auditor looked
at the presenting complaint and the triage nurses assessment. She compared her own CTAS code with the one
assigned by the RN. The expert reviewer verified her
triage designation by using current CTAS guidelines,33-35
which is the gold-standard approach.36 The accuracy rate
for both groups was calculated, and the emergency nurses
triage scores were compared with the experts scores by use
of a Fisher exact test.
The total number of messages in the online discussion
forum was tracked by the system software. Descriptive
statistics and a t test were used to compare the volume
of messages generated by nurses in the C and E groups.
Descriptive statistics were used to summarize total and
subscale scores on the OLSI within groups. We decided
to use nonparametric procedures given that the LDS and
OLSI scores represent ordinal levels of measurement. A
Kruskal-Wallis test was used to compare scores on the
OLSI between groups. The 2 groups were compared by
use of nonparametric tests on responses to certain items
on the OLSI including pretest and post-test scores for
computer skills.
Results

LEARNER DEMOGRAPHIC SURVEY

Of those enrolled in the course, 132 (76.7%) returned the

LDS. The majority of respondents were women aged
between 35 and 54 years. There was no statistically significant difference between the E and C groups with respect
to age group, sex, education, years of experience, hospital
setting (rural or urban), or computer experience (P > .05
for all). Most RNs (72.5% [n = 98]) were enrolled in their
first computer-based course. Forty-two percent (n = 56)
ranked themselves as a beginner or novice in their overall
computer skills. A comparison of pre- and post-course
computer skills showed that there was improvement in
overall computer abilities within both the E and C groups
(P < .01) and there was no statistically significant difference between groups. The workplace project in the E
group had a major impact on the RNs clinical and triage
practices. The project facilitated the transfer of triage
learning from the course to the individual and from the
individual to other staff and administrators in the emergency department.
ONLINE LEARNER SUPPORT INSTRUMENT

A total of 122 RNs returned the OLSI; however, not all

respondents completed each subscale. The scores for the
RNs level of satisfaction with Web-based learning ranged

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from 71 to 165 (which equates to a normalized score of

44 out of 100). There were almost identical numbers of
E and C subjects rating their levels of satisfaction. The
higher the total score, the more positive the online learner
support experience. The mean for the total OLSI score
for the E group was 124.41 (SD, 17.3), or 75.4 of
100, and the mean for the C group was 123.37 (SD,
17.8), or 74.7 of 100. There were no statistically significant differences in total OLSI scores (P = .33) or any of
the subscale scores between the E and C groups.
With respect to the subscale for interactions with teacher and peers, 70% (n = 86) of the RNs reported that they
felt part of a learning group whereas 63% (n = 77) said
their online discussions with peers had been helpful to their
learning. Results from the environment subscale showed
that 60% (n = 44) of work users reported that they enjoyed
taking the online course at work. Moreover, 74% (n = 55)
reported that they had convenient access to a computer at
work. However, 53% (n = 39) reported that there was not
enough time to learn CTAS at work; 27% (n = 20) said
there were not enough computers, and 41% (n = 30) noted
that the computer was in an unsuitable location for online
learning. Of work users, 92% (n = 68) thought that group
enrollments were a good idea, whereas 95% (n = 105) of
home users reported that they found it convenient to take a
course from home. Results from the course design subscale
showed that 76% (n = 94) reported that the use of patient
simulations was helpful to their learning and 78% (n = 97)
found that the course content was presented in a way that
was easily understood. Only 59% (n = 73) noted that it
was easy to identify new messages and follow a topic in
the online discussion forum. The overall impressions subscale results indicated that 78% of the RNs (n = 97) noted
that their knowledge of triage had improved. Moreover,
75% (n = 92) reported that they were able to triage patients
more accurately after completion of course. Cronbach
values for this study for all subscales were over .80, with
the exception of the work environment subscale, where
the was .76.
TRIAGE ACCURACY

When patients are admitted to the emergency department,

they are assigned to 1 of 5 CTAS categories, which influences how quickly they are seen by a physician and reassessed by an RN (Table 1). A total of 367 charts were
retrieved and evaluated (183 from the E group and 184
from the C group). Of these, 69.8% (n = 256) were identified as correctly triaged by the emergency nurse expert.
The accuracy rate was 72.1% (n = 132) for the E group
and 67.3% (n = 124) for the C group. Although we believe
this difference to be clinically significant, a Fisher exact test

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FIGURE 1
Under- and over-triaging based on E and C group chart audits.

showed that the difference was not statistically significant

(P = .36). Overall agreement between the RNs and the
expert reviewer within 1 triage level was 99.7%.
Of those charts that were inaccurately coded, 46.8%
(n = 52) were under-triaged, meaning that the patient
should have been assigned a more urgent code. Fifty-three
percent (fifty-nine charts) were over-triaged, meaning that
the patient should have been assigned a less urgent code.
The C group had significantly (P < .01) increased numbers
of under-triaged patients (n = 43) in comparison to the E
group (n = 9). The E group had significantly (P < .01)
increased numbers of over-triaged patients (n = 42) in comparison to the C group (n = 17) (Figure 1).
ONLINE DISCUSSION

The mean number of messages in the online forum was

18.6 (SD, 6.6) for the C group and 16.5 (SD, 4) for the
E group. The results of the t test indicated that there was
no significant difference in the number of messages posted
to the forum (t = 0.622, df = 9; P = .55).
Discussion

A major finding was that the online CTAS course positively impacted nurses triage skills. The triage accuracy rate
for all nurses was 70%. This figure compares favorably
when measured against previous reports of triage accuracy.36 The overall agreement between the RNs and expert
within 1 triage level was 99.7%, which is also very positive.
This implies that RNs can reliably use the CTAS. The
70% agreement between the expert and RNs provides
further evidence for the work done by other investigators

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regarding the reliability of the CTAS scale.34 It is important to examine the 30% that were incorrectly triaged; of
these, 53% were over-triaged. The majority (71%) of the
over-triaging was done by RNs in the E group. This is a
resource issue and a practice that errs on the side of patient
safety. Triage personnel are typically encouraged to triage
up even if the patient does not clearly present with the
signs and symptoms that match with the higher triage
level. 34 Of greater concern are the patients who were
under-triaged, 83% of whom were triaged by nurses in
the C group. The implications of under-triaging are more
serious: increased patient wait times and poor outcomes if
necessary care is delayed.
Although the hypothesis that a mandatory tutorial,
awarding of marks for online discussion, and a workplace
project would improve nurses satisfaction and enhance
triage accuracy was only partly supported, a great deal
was learned about online learning. The overall OLSI satisfaction rate of 75% with the Web course is consistent with
earlier studies.9,11,30
The finding of no significant difference in nurses
satisfaction with the course was initially surprising. On
closer examination, the reasons for this become clear.
Even without the 25% grade incentive, RNs in the C
group talked online as frequently as those in the E
group. This suggests that if the online discussion is sufficiently interesting, professionals will join voluntarily.
Although the online tutorial was mandatory for RNs in
the E group, all but 2 RNs in the C group chose to do
the tutorial. This means that the 2 groups experiences
ultimately differed only with respect to the workplace project. The finding that nurses who completed the workplace project made significantly fewer errors of clinical
importance (under-triaging) is important and warrants
further study. Moreover, the accuracy of the RNs triage
assessment affects patient safety as well as hospital accreditation. Only 16% (n = 20) had an unsatisfactory experience with the course; the majority of these RNs were
already very experienced with CTAS and were seeking
more in-depth content. In retrospect, they were overqualified for this level of CTAS course. The finding that
nurses increased their computer skills is similar to earlier
studies17,37,38 and suggests that learners may benefit by
taking even relatively short computer courses.
Limitations

There was no statistically significant difference in triage

accuracy between RNs (in either group) and the ED
expert. Perhaps a larger sample size in future research
would detect a statistical difference. However, there was

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TABLE 2

Recommendations for Developers and Employers

Based on Study Results
Course developers

Marketing
Provide complete course descriptions to assist learners in
making decisions about course enrollment
Technology
Select well-tested platform with minimal training
Ensure that message management is easy to learn and
facilitates posting and retrieval
Provide platform interface familiar to students
Course design
Provide a tutorial that orientates students to computer
skills required in the course
Provide level tutorial based on learners' computer skills
Provide novices with opportunity to test their skills (eg,
send an attachment)
Make the tutorial available as soon as a student registers
Make the tutorial open and free to anyone visiting
your site
Leave the tutorial online throughout the course
Provide learning and evaluation activities that relate to
clinical practice
Implement workplace project completed individually or
in groups
Provide online opportunity for learners to showcase their
projects
Customize course by adding enriching activities, readings, or optional modules
Provide online discussion forum to enhance learning
and networking
Subdivide large classes into groups of 10 to 12 to keep
online discussion manageable
Develop interesting, practice-based learning activities
Employers

Examine the organizational strategic plan for staff development

Determine whether sufficient resources and IT support
are in place for online learning
Provide release time
Provide sufficient hardware
Provide quiet learning environment if online learning is
expected to take place at work
Facilitate group enrollment and workplace projects
linked to Web courses

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a statistically significant difference between the groups

with respect to the direction of triaging (ie, under- vs
over-triaging). The chart audit should be replicated to
obtain evidence of the impact of E-learning on triage
accuracy. A qualitative study could be conducted on the
nature and depth of the online discussion. Replication of
the study with groups such as emergency physicians to
measure the impact of online CTAS training would
be interesting.

12. Novaczek I, Gabriel M. Learning from a pilot project to put a college

IT curriculum online. Educ Technol Soc. 2002;5(1):60-6.

Implications for Emergency Nurses

16. Alpay L, Russell A. Information technology training in primary care: the

nurses voice. Comput Inform Nurs. 2002;20(4):136-42.

On the basis of the findings of this study, a number of

recommendations were developed and are listed in
Table 2.

17. Atack L, Rankin J. A descriptive study of Registered Nurses experiences

with web-based learning. J Adv Nurs. 2002;40(4):457-65.

Conclusions

The online CTAS course provided a standardized and

effective educational experience that improved triage accuracy. The workplace project enhanced transfer of learning
to the workplace. Technology will increasingly be used to
maintain professional competency. Further research will
provide evidence for best practices in E-learning.
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