636360

research-article2016
CNRXXX10.1177/1054773816636360Clinical Nursing ResearchChang et al.

Article
Clinical Nursing Research
1­–16
Using the Five-Level © The Author(s) 2016
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DOI: 10.1177/1054773816636360
Acuity Scale cnr.sagepub.com

Computerized System:
Factors in Decision Making
by Emergency Department
Triage Nurses

Wen Chang, RN, MN1,2, Hsueh-Erh Liu, RN, PhD2,

Suzanne Goopy, RN, PhD3, Li-Chin Chen, RN, MN4,
Hsiao-Jung Chen, RN, MN1,
and Chin-Yen Han, RN, PhD1

Abstract
Triage classifies and prioritizes patients’ care based on the acuity of the illness
in emergency departments (EDs). In Taiwan, the five-level Taiwan Triage
and Acuity Scale (TTAS) computerized system was implemented nationally
in 2010. The purpose of this study was to understand which factors affect
decision-making practices of triage nurses in the light of the implementation
of the new TTAS tool and computerized system. The qualitative data
were collected by in-depth interviews. Data saturation was reached with
16 participants. Content analysis was used. The results demonstrated

1Chang Gung University of Science and Technology, Taiwan, ROC

2Chang Gung University, Taiwan, ROC
3University of Calgary, Alberta, Canada
4Chang Gung Memorial Hospital, Taiwan, ROC

Corresponding Author:
Chin-Yen Han, Assistant Professor, Department of Nursing, Chang Gung University of
Science and Technology, 261, Wenhua 1st Road, Guishan, Taoyuan City, 33303,
Taiwan, ROC.
Email: cyhan@gw.cgust.edu.tw

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2 Clinical Nursing Research 

that the factors affecting nurses’ decision making in the light of the newly
implemented computerized system sit within three main categories: external
environmental, patients’ health status, and nurses’ experiences. This study
suggests ensuring the patient’s privacy while attending the triage desk,
improving the critical thinking of triage nurses, and strengthening the public’s
understanding of the ED visits. These will make ED triage more efficient.

Keywords
Taiwan Triage and Acuity Scale, decision making, five-level triage scale,
electronic triage system, emergency nursing

Introduction
It is a global problem that the number of patients admitted to emergency
departments (EDs) continues to increase and that this leads to ED overcrowd-
ing (Anneveld, Linden, Grootendorst, & Galli-Leslie, 2013). The provision
of emergency care is based on the urgency of the patient’s condition (Dallaire,
Poitras, Aubin, Lavoie, & Moore, 2012). A strong triage system is the back-
bone of an efficient ED and is critical to effective implementation of an ED
triage system (Ajani, 2012). The role of the ED triage nurse is therefore an
important one. Triage decisions have an impact on patient health outcomes,
time to treatment and overall length of stay, and patient satisfaction (Stanfield,
2015). Making such decisions is a big challenge for ED triage nurses, who
must be able to make correct decisions quickly in a hectic and emotional
environment.

Background
In Taiwan, the five-level Taiwan Triage and Acuity Scale (TTAS) computer-
ized system was implemented in 2010 to replace the previous four-level man-
ual triage system. The four-level ED triage system has been used in all the
tertiary hospitals in Taiwan since 1999 (Chiu et al., 2008). Ng et al. (2010)
found that the four-level ED triage system used in Taiwan fails to effectively
reflect the urgency and severity of patents’ diseases as compared with the
five-level triage system. Therefore, the five-level TTAS was later developed
as well as the TTAS computerized system. In 2010, TTAS computerized sys-
tem was officially launched in Taiwan.
TTAS was developed by the Taiwan Society of Emergency Medicine and
Taiwan Association of Critical Care Nurses based on the framework of the

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Chang et al. 3

Canadian Triage and Acuity Scale (CTAS). TTAS is a five-level ED triage

system that moves from Triage Level 1 (resuscitation) to Triage Level 5 (not
urgent). The TTAS computerized system determines level of triage according
to patients’ chief complaints, which can be further divided into two systems
of non-traumatic injuries and traumatic injuries. The two systems include 14
categories (respiratory, cardiovascular, gastrointestinal, neurological, skele-
tal, urinary, general and other, ENT, ophthalmology, dermatology, maternity,
mental illness, environment, and substance abuse) with 163 chief complaints.
The TTAS computerized system assesses triage level according to (a) exist-
ing chief complaints; (b) primary adjustment variables: vital signs (including
degree of respiratory distress, hemodynamic stability, conscious level, change
in body temperature, and pain severity); and (c) mechanism of injury (for
patients with trauma), to determine the triage level of patients. In the cases
when chief complaints cannot be determined by primary adjustment vari-
ables, the semi-adjustable variables can be used. It is designed as an elec-
tronic decision support system for assessment and determination of ED
patient treatment priority (Chiu et al., 2008).
Clinically, when a patient arrives in the ED, the triage nurse will first
ascertain the patient’s chief complaint and quickly perform a systematic
assessment. All the relevant information will be entered into the triage com-
puter system to decide the triage level. Triage decision making is a dynamic
process in which ED triage nurses need to make decisions in a tense and
uncertain environment, under time pressure, and with limited usable informa-
tion from the patients (Reay & Rankin, 2013). Inadequate decisions on triage
may delay the medical treatment needed by patients and may lead to serious
consequences (Göransson, Ehrenberg, & Ehnfors, 2005). Decision making
usually involves choosing the best solution from at least two options (Beach,
1993). It is a cognitive process to make a strategic decision through message
identification, thinking, and judgment (Banning, 2008). The decision mak-
er’s values, ideas, experiences, and cognition may affect the efficiency of
decision making as may the decision maker’s personal goals and abilities and
environmental factors (Lin, Chang, Yang, Kao, & Lu, 2006). Nurses make
nursing decisions on patients’ health problems according to their personal
knowledge background, past experiences, and intuitive ideas, and they deter-
mine their nursing implementations after critical thinking (Bakalis & Watson,
2005). This critical thinking has been emphasized as an essential element in
the process of nursing decision making (Cone & Murray, 2002). Studies indi-
cate that the nurses making such decisions interact according to personal
knowledge, experience, and cognition, as well as according to medical unit
cultural factors (Banning, 2008; Currey & Botti, 2006). Most studies that
have focused on ED triage have been more quantitative in design and have

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4 Clinical Nursing Research 

tended to look at triage acuity (Garbez, Carrieri-Kohlman, Stotts, Chan, &

Neighbor, 2011; Martin et al., 2014; Wolf, 2013). There is limited research
related to the factors that influence an ED nurse during the triage process
(Cone & Murray, 2002; Wolf, 2010).

Purpose of the Study

The purpose of this study was to understand the factors influencing decision
making in ED triage nurses applying the TTAS system in Taiwan.

Method
Design
The study adopted the qualitative descriptive approach. The value of qualita-
tive description lies not only in the knowledge that can originate from it but
also in presenting and treating research methods as living entities that resist
simple classification. A qualitative descriptive study can establish meaning
and solid findings (Sandelowski, 2010). The expected outcome of this study
was to understand the factors affecting the decision making of ED triage
nurses using the new five-level TTAS computerized system.

Sample
The study was conducted in a Medical Center hospital of more than 3,700
beds in Taiwan where approximately 15,000 ED visitors per month were
treated. The data were collected from April to December 2012. The eligibility
criteria for participation were registered nurses (a) who had been employed
in the ED for more than 2 years, (b) had undertaken TTAS training and
engaged in ED triage, (c) who were aged 20 years and older, and (d) who
were willing to participate in this study.

Data Collection
The interviews were conducted privately in a meeting room in the participat-
ing hospital. The meeting rooms needed to be booked first and had locking
facilities from the inside. Each meeting room is located outside the EDs where
the participants worked. This interview setting was intended to help the par-
ticipants to feel in a safe and less distressing environment and to talk about
their experiences freely. A semi-structured interview was used. To have inter-
view consistency, the study used the same qualitative researcher to conduct all

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Chang et al. 5

interviews. The interviewer began with a simple, familiar question such as,
“What was work like today?” This was helpful to get participants to start talk-
ing about their practice. The interviewer then encouraged the participants to
focus the discussion on their practice of ED triage and TTAS. Interview ques-
tions included “Could you give me some examples of using the TTAS for tri-
age ED patients?” or “Tell me about your experience of using the TTAS with
ED patients.” Clarifying questions included “Could you explain that further?
What do you mean by that?” Such clarifying questions served as prompts
when explanations were unclear or when the interviewer did not understand
the participant’s meaning (Green & Bowden, 2005). Data saturation was
reached with 16 emergency nurses. The length of interviews for the study
varied from 20 to 46 min.

Data Analysis
Each interview was conducted and audio taped. Content analysis was used
in data analysis. Content analysis is a systemic coding and categorizing
approach used for exploring large amounts of textual information to deter-
mine patterns of words used, their relationship, and the structures and dis-
courses of communication interview data in a study (Gbrich, 2007). The
purpose of content analysis is to describe the characteristics of the document
content by examining who said what and with what effect (Gbrich, 2007).
The process of content analysis in this study is based on the work of Elo and
Kyngäs (2008). In the preparation phase, the researchers transcribed the
interviews and read them several times to obtain a sense of the whole. This
was followed by open coding, creating categories, and grouping codes. The
researchers read the transcripts several times to become immersed in the
data. Similar meanings were grouped into themes. This process continued
until no new themes emerged.

Trustworthiness
Credibility, dependability, conformability, and transferability are the most
common measures of trustworthiness in qualitative studies (Lincoln &
Guba, 1985). To achieve these goals, the following strategies were used.
Data were initially coded by the individual researchers working indepen-
dently, and then, the researchers worked collaboratively. The researchers
worked collaboratively to develop and revise the codes and categories dur-
ing the data analysis process. The researchers had experience in ED triage
and qualitative research, which increased the credibility of the study.
Transferability was emphasized by using in-depth information to reach a

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6 Clinical Nursing Research 

complete data style and show its relevance and context. To develop a rich
descriptive classification, the study collected sufficient information to
reach data saturation. Excerpts are provided from the interviews to support
the dependability of the research by providing evidence for the categories
into which interview data have been sorted and the researchers’ interpreta-
tion of this data, the categories themselves, and the relationship between
the categories. Conformability was achieved by maintaining an audit trail
and research reflection log. Member checking was conducted to validate
findings. All steps in the study’s data analysis faithfully described the par-
ticipants’ experiences.

Ethical Considerations
Before enrolling the subjects, the researchers fully explained the research
purpose, data collection process, time required, and data confidentiality to the
participants. The interviews were performed after the subjects gave both ver-
bal and written consents. This study was approved by the hospital’s institu-
tional review board.

Results
Demographic Characteristics of Participants
Sixteen ED triage nurses participated in the study. All the participants were
female, with ages ranging from 25.8 to 38 years. Their ED working experi-
ence was from 3 to 15.7 years, and their triage experience from 1 to 12 years.
Seven of total 16 participants (43.75%) had a bachelor’s degree, and nine
participants had an associate degree (56.25%). The average interview time
was 39 min.

Factors Affecting Nurses’ Triage Decision Making

The results showed that the factors affecting nurses’ use of the TTAS comput-
erized system for ED triage can be divided into three categories: the external
environment, patients’ health status, and nurses’ experience (Figure 1).

Category 1: External environment. The external environment factors can be

divided into three parts: the open ED triage environment, conflicts at work,
and available equipment and devices. The results indicate that the triage deci-
sion making is adversely affected by lack of privacy in the triage area,
patient–nurse conflict, and the limited equipment available in the ED.

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Chang et al. 7

Table 1.  Characteristics and Demographics of the Participants (N = 16).

Items n (%) M (±SD)

Age 32.44 (±3.85)
Gender  
 Female 16 (100%)  
Education  
  Associate degree 9 (56.25%)  
  Bachelor’s degree 7 (43.75%)  
Registered nurse work experience 11.13 (±4.21)
(years)
ED work experience (years) 8.81 (±3.64)
ED triage work experience (years) 6.37 (±3.44)

Note. ED = emergency departments.

Open ED triage environment.  In Taiwan, the ED triage area is allocated at

the main entrance of ED with an open space. The ED registration counter and
security officer are located next to the ED triage area. The open ED triage
environment results in a lack of patient privacy and may cause patients to
withhold some details about their diseases/symptoms. When the ED patient
and family member provide less information, this may affect the ED nurse’s
ability to make adequate triage decisions.

I feel hampered because the ED triage environment is too open. . . . The patients
have little privacy. Sometimes, they seem like they are about to tell something,
then they hold back, so I do not know whether their level of triage is appropriate.
(P14)

Conflicts and interruption during work. During the ED triage process,

patients tend to lose their patience after a long wait time, complaining to
nurses and arguing with them. This causes the nurses to speed up in their tri-
age practice, in turn, affecting their triage decision making.

The ED is more crowded than it was . . . I hope that all patients can wait in line
for their turn, otherwise my triage is affected. I am anxious to perform triage,
but they (the patients) are more anxious. Sometimes, patients just cut in line
and have a mass confrontation with staff, which affects my decision. (P3)

. . . one time I spent only 20 minutes to finish triage on 15 patients, because I

was afraid that there would be more patients (or their families) crowding into
the ED and they would complain about my speed. (P5)

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8 Clinical Nursing Research 

Figure 1.  Factors affecting nurses’ ED triage decision making.

Note. ED = emergency departments.

Available equipment and devices.  Because the equipment in the ED is lim-

ited, nurses need to consider whether the devices can meet a patient’s needs.
Hence, equipment and devices are one of the factors affecting triage decision
making.

Suction cannot be performed at areas II [Levels 3 and 4 triage] and V [Level 5].
If the patient looks like having too much sputum and saliva, I would change his
triage level so that he can receive suction at area I [Levels 1 and 2]. (P14)

Category 2: Patients’ health status when attending triage desk.  The triage level is
determined according to the health status of patients when they are admitted to

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Chang et al. 9

the ED. The health status can be divided into the following categories, all of
which have an impact on triage decisions: the patient’s main problem, past med-
ical history, objective data and instrument parameters, and overall appearance.

I think vital signs and level of consciousness are more important, as well as the
patient’s appearance. For example, when a patient looks pale, he/she may be
suffering from anemia [hemoglobin value between 5 and 7 gm/dl]. I will
consider assigning triage level 2. (P4)

. . . usually, they are elderly, I would check their blood oxygen level; if it is low,
I may let them see the doctor first. (P9)

When I make a decision, I will base it on the patient’s main complaint, medical
history, past history, LMP history, medication. (P10)

Category 3: Nurses’ experience.  The experience of nurses can be divided into

two parts: ED working experience and intuition and proficiency in system
operation. Extensive experience in working in ED and proficiency in using
the TTAS computerized system were seen as improving triage decision
making.

ED working experience and intuition.  ED triage nurses felt that past experi-
ence working in an ED was helpful to the triage process. They felt the same
about intuitive responses, which can make the triage decision more accurate.

I go through patients quickly . . . I think that sensitivity [of ED care] is very

important . . . ED nurses need to rely on their experiences and make decisions
immediately . . . I think I can use my experience to select the more appropriate
triage level in the system. (P3)

ED nurses rely on feelings. I mean that’s all about how I feel. When we are
more experienced on ED triage, we may spend more time on triage and ask
more detailed questions. If we are new to the triage team, we don’t ask many
questions . . . our questions are not detailed . . . I think that experience is
important to triage. (P7)

Proficiency in system operation.  Because of the high number of “chief com-

plaint” choices in the TTAS computerized system, ED triage nurses thought
that proficiency in operating the system was also an important factor affect-
ing ED triage.

If I only allocate to triage once in a while, I will only choose certain items from
the system. Because there are many items and many divisions I am not

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10 Clinical Nursing Research 

unfamiliar with. . . . I may never choose those items, thus may affect the triage
level. (P9)

. . . although the training did explain the system and practice. It would be a
little rusty regarding to the operation the system if I did not use the ED triage
computerized system frequently. This definitely affects the triage decisions.
(P3)

Discussion
The study found that the factors affecting nurses’ use of the TTAS computer-
ized system for ED triage can be divided into external environmental,
patients’ health status, and nurses’ experience. The research results are con-
sistent with previous studies, which mention that nurse’s decision making is
affected by conflicts at work, nursing experiences, intuition, education, and
professional knowledge (Bakalis & Watson, 2005; Cone & Murray, 2002).
Chung (2005) found that time limitation and lack of nurse training affect the
triage decision-making process, which is consistent with the results of this
study. The three categories are discussed below.

External Environment
In Taiwan, the medical system imposes no restrictions on patients admitting
to the ED. Because of the convenience of ED services, the fact that ED ser-
vices are provided free of charge, the relatively shorter waiting time, and
personal preference, Taiwanese people often regard the ED as a shortcut to
immediate medical care (Liang, Tsai, & Chen, 2011). The number of patients
accessing EDs rose from 6.87 million per year in 2003 to 7.33 million in 2014
(Ministry of Health and Welfare, 2015). The number of patients admitted to
EDs has progressively increased, although 51.97% of ED patients were triage
level with non-urgent situations (Liang et al., 2011). This situation has led to
overcrowding in EDs, patient–doctor conflicts, and an increased workload
for ED staff (Liang et al., 2011). Our study found that ED triage nurses are
stressed by the large number of ED patients. Moreover, following a long wait,
patients or their families may engage in conflict with ED triage nurses. Under
such a heavy workload, ED triage nurses are unable to assess the condition of
patients in detail, further affecting triage decision making. These findings are
similar to those of the studies by Wolf (2010, 2013).
Because the accuracy of ED triage is affected by these factors in the
departmental environment, health authorities and medical institutions are
advised to educate the public about ED admission. The concept of ED triage

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Chang et al. 11

should also be promoted. An ED treats patients according to the severity of

their condition; hence, patients admitted to EDs may not receive treatment
immediately. Public understanding can decrease the misuse and waste of
emergency medical resources, reduce the workload and conflicts of ED staff,
and improve the quality of emergency care. Moreover, the equipment in an
ED should be capable of meeting the needs of every patient. EDs are advised
to purchase mobile equipment and devices to avoid decisions being made
based on a lack of resources. More importantly, although medical workers are
obligated to protect patients’ privacy (Yang, 2012), our study found that the
open environment of ED triage discourages patients from disclosing all per-
sonal details. Therefore, we suggest that the design of triage area should con-
sider the patient confidentiality. The provision of an appropriate private
environment would enable patient to disclose their problems freely and
allowing triage nurse to collect accurate information.

Patients’ Health Status

The TTAS computerized system assesses the triage level of patients accord-
ing to their chief complaints, vital signs, level of consciousness, and pain
severity. Therefore, chief complaints are an important factor affecting nurses’
use of the TTAS computerized system for ED triage. Studies indicate that the
important factors affecting ED triage decision making include quantitative
data related to the patient’s health status (e.g., vital signs; Castner, 2011;
Chung, 2005; Cooper, Schriger, Flaherty, Lin, & Hubbell, 2002; Garbez,
Carrieri-Kohlman, Stotts, Chan, & Neighbor, 2011; Wolf, 2010). ED triage
nurses are advised to enhance their communication and assessment skills,
nursing techniques, professional knowledge, and ability to make sensitive
judgments to collect subjective and objective data from patients accurately as
the basis for ED triage.

Nurses’ Experiences
Studies have found that a nurse’s decision-making process is affected by the
complexity of the work (Arslanian-Engoren, 2009; Cone & Murray, 2002;
Wolf, 2010). The medical care provided by EDs ranges from non-urgent situ-
ations to immediate resuscitation (Robinson, 2013). In addition, triage is the
most challenging work performed by ED nurses (Bambi, Scarica, Becattini,
Alocci, & Ruggeri, 2011). Our study found that the diversity of ED patients’
diseases and conditions, the open working environment, the large number of
patients, and conflicts with patients and their families all contribute to the
complexity of ED triage work and so affect nurses’ decision making.

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12 Clinical Nursing Research 

Visual clues such as patients’ physical appearance play a very important

role during the ED triage assessment with such clues, including not only the
available objective data but also the drawing on previously acquired knowl-
edge related to the type of situation and the probability of certain outcomes,
on the part of nurses (Chung, 2005). As the literature suggests, decision
making is subject to personal experience, personal traits, and talents, but it
can also be cultivated and practiced. Research has also found that nurses rely
on heuristics or the professional knowledge of colleagues to perform clinical
decision making (Arslanian-Engoren, 2009; Cranley, Doran, Tourangeau,
Kushniruk, & Nagle, 2009; Reay & Rankin, 2013; Stanfield, 2015). As
Stanfield (2015) argued, triage nurses use their education and past experi-
ence to make inferences during the practice. The findings from this study
add further support to this body of literature insofar as they suggest that to
strengthen nurses’ professional knowledge, enhance their decision-making
skills and improve their knowledge of, and ability in, ED triage, both in-
service training and nursing education are needed to further improve the
effectiveness of triage in the ED. There are a number of ways that this can
take place with strategies, including participation of ED nurses in multidis-
ciplinary conferences, scenario simulations that can also be used for case-
practice, and TTAS computerized system training, with regular refresher
training provided to ensure that nurses continue to use the TTAS system in
the most effective way. Finally, workshops can be held for ED triage nurses
to discuss and share their experiences to sharpen their critical thinking abil-
ity, clinical response ability, and proficiency at system operation. Together,
these strategies can help to ensure that ED triage nurses are making the most
accurate ED triage decisions at all times.

Strengths and Limitations

This study uses a qualitative approach with a focus on emergency nurses
from one ED in Taiwan to explore the factors influencing ED nurses’ triage
decision making. The knowledge to emerge from the research can be used as
a basis for the development of better approaches to support nurses’ clinical
and professional practice in emergency nursing. The common limitation of
qualitative research lies in the generalizability of its research outcomes. This
study was conducted in only one ED in Taiwan. This study had no intention
to generalize the study to a larger population but rather to represent the under-
standing of the ED nurse within the context of using TTAS computerized
system. Therefore, the results from the current study cannot necessarily be
extended to the factors affecting ED triage decision making for all nurses in
Taiwan. The use of the TTAS computerized system has become a part of the

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Chang et al. 13

routine practice for ED nurses. This study has not explored the level of con-
fidence of triage nurses using the TTAS, which is an acknowledged limitation
of this study.

Conclusion
ED triage should be performed accurately, as the priorities in medical treat-
ment for ED patients are determined according to the observed severity of
their condition. This study found that the external environment, the health
status of patients, and nurses’ experience all affect nurses’ ED triage decision
making. It recommends ensuring the patient’s privacy in attending the triage
desk, improving nurses’ critical thinking ability, and strengthening the pub-
lic’s understanding of ED admission, to reduce the influence of these factors
on ED triage decision making. Future studies are recommended to investigate
the interrater reliability of the TTAS computerized system among ED triage
nurses to understand the reliability of ED triage decision making. The find-
ings are expected to serve as references for nurses in using the five-level
TTAS electronic system for ED triage, therefore making the ED triage deci-
sion making more efficient and accurate.

Relevance to Clinical Practice

The outcomes from this study can be applied in the following ways. In terms
of emergency clinical care, these results confirm that the work experience of
ED triage nurses affects their decision making. Experienced nurses should
work in the ED triage, and the triage decision-making process should become
more efficient and correct. For nurse managers, the results can encourage
administrators first to provide appropriate in-service training to further
improve ED nurses’ triage practice, and second, to improve the patient pri-
vacy when attending the triage desk. Nurse educators could use the knowl-
edge to reduce the gap between education and practice. The study suggests
the development of decision-making patterns in emergency patients and their
families as a topic for future research. Further research can help us under-
stand the differences that emergency patients and their families may have
with ED clinical nurses to the benefit of ED triage implementation and nurs-
ing care.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

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14 Clinical Nursing Research 

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: The authors thank the research funding
provided by Chang Gung University of Science and Technology(EZRPF3B0031) and
the Chang Gung Memorial Hospital (BMRPB93).

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Author Biographies
Wen Chang, RN, MN, is a doctoral student in Graduate Institute of Clinical Medical
Sciences at the Chang Gung University and a lecturer in the Department of Nursing at
Chang Gung University of Science and Technology, Taiwan.
Hsueh-Erh Liu, RN, PhD, is a professor in the School of Nursing at the Chang Gung
University, Taiwan.
Suzanne Goopy, RN, PhD, is an associate professor in the Faculty of Nursing at the
University of Calgary, Canada.
Li-Chin Chen, RN, MN, is a deputy director in the Department of Nursing at Chang
Gung Memorial Hospital, Taiwan.
Hsiao-Jung Chen, RN, MN, is a lecturer in the Department of Nursing at Chang
Gung University of Science and Technology, Taiwan.
Chin-Yen Han, RN, PhD, is an assistant professor in the Department of Nursing at
Chang Gung University of Science and Technology, Taiwan.

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