Accepted Manuscript

Comparison of scenario based triage education by lecture and role

playing on knowledge and practice of nursing students

Samira Delnavaz, Hadi Hassankhani, Fariborz Roshangar, Abbas

Dadashzadeh, Parvin Sarbakhsh, Mansour Ghafourifard,
Eskandar Fathiazar

PII: S0260-6917(18)30397-6
DOI: doi:10.1016/j.nedt.2018.08.006
Reference: YNEDT 3933
To appear in: Nurse Education Today
Received date: 24 October 2017
Revised date: 18 June 2018
Accepted date: 9 August 2018

Please cite this article as: Samira Delnavaz, Hadi Hassankhani, Fariborz Roshangar, Abbas
Dadashzadeh, Parvin Sarbakhsh, Mansour Ghafourifard, Eskandar Fathiazar , Comparison
of scenario based triage education by lecture and role playing on knowledge and practice
of nursing students. Ynedt (2018), doi:10.1016/j.nedt.2018.08.006

This is a PDF file of an unedited manuscript that has been accepted for publication. As
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Title: Comparison of Scenario based Triage education by lecture and role playing on
knowledge and practice of nursing students

Journal name: Nurse education today

Running title: Scenario based Triage education by lecture and role playing

Authors: Samira Delnavaz1, Hadi hassankhani2, Fariborz Roshangar3, Abbas Dadashzadeh*4,

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Parvin Sarbakhsh5, Mansour Ghafourifard6, Eskandar Fathiazar7

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1
Master of nursing student , Nursing & Midwifery Faculty, Tabriz University of Medical
sciences, Tabriz, Iran
2
Associate Professor, Center of Qualitative Studies, Department of Medical Surgical Nursing,

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School of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
3
Assistant Professor, Department of Medical Surgical Nursing, School of Nursing and
Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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*4
Nursing PhD student, Department of Medical Surgical Nursing, Faculty of Nursing and

Midwifery, Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz,
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Iran. (Corresponding author)

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5
Assistant Professor of Biostatistics, Department of Statistics and Epidemiology, Health Faculty,
Tabriz University of Medical sciences, Tabriz, Iran
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6
Assistant Professor, Department of Medical Surgical Nursing, School of Nursing and
Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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Professor, Education & Psychology Faculty, Tabriz University of Medical sciences, Tabriz,
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Iran
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Address: Department of medical surgical nursing, faculty of nursing and midwifery, Shariati-

jonubi st., Tabriz, Iran.

Postal code: 4515789589. Tel: +9833772513

E-mail: dadashzadeha@ tbzmed.ac.ir

Acknowledgments
This project was derived from the master's thesis conducted in Tabriz faculty of Nursing and
Midwifery. Hereby, the authors appreciate all students who participated in this study.
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Comparison of scenario-based triage education by lecture and role-playing on knowledge

and practice of nursing students

Abstract

Introduction: Quick and accurate triage of patients in the emergency department is a key factor

for successful management of the emergency situations and ensuring the quality of care.

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Moreover, triage skills education is one of the important aspects of preparedness of nurses for

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different emergency situations. The objective of this study was to compare the effect of

educating emergency severity index (ESI) triage using lecture and role-playing on the knowledge

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and practice of nursing students.

Methods: This experimental study was conducted in the School of Nursing and Midwifery,
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Tabriz, Iran, in 2016. In this study, 56 nursing students were selected by convenience sampling
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method and were randomly divided into two groups. Triage scenarios were taught and presented

in two ways by using lecture or role-playing method. One month later, the post-test was taken.
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Data were collected using a questionnaire assessing the knowledge and practice of ESI and were
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analysed using SPSS (version 21).

Results: The mean knowledge and practice scores in both groups improved significantly (P <
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0.05). The post-test score showed a significant difference between the two groups, and the mean
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score was higher in the role-playing group compared with that of the lecture group (P < 0.05).

Discussion: The results showed the effectiveness of both educational methods on students'

learning. However, the role-playing method was more effective than the lecture method and is

recommended for triage education. In addition, according to the importance of triage, developing

the theoretical and practical education courses for nursing students is recommended.
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Keywords: Emergency department, triage, emergency severity index, education, role-playing,

lecture

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Introduction

Triage means prioritizing patients for admission and treatment in emergency departments

according to their medical conditions (Fernandes et al., 2005; Gilboy et al., 2012; Safari et al.,

2015). Quick and accurate triage of patients in the emergency department is a key factor for

successful management of the emergency situations (Dadashzadeh et al., 2013). For this purpose,

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a wide range of triage systems are used around the world to prioritize the patients in the

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emergency departments (Christ et al., 2010; Tanabe et al., 2007). The five-level emergency

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severity index (ESI) system has been accepted as the standard measure and is commonly used in

emergency departments worldwide, including Iran (Christ et al., 2010; Maleki et al., 2015).

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Nurses are responsible for the triage, and they must be trained and prepared for this
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responsibility (Mahmoudi et al., 2017; Pardey, 2007; Recznik and Simko, 2018). Without

providing proper and effective education, they will not be able to use triage accurately (Mirhaghi
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and Roudbari, 2011). For this, the nursing faculties must be able to expose the nursing students
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to the critical situations to be prepared for the triage. Viewing emergency situation and working

in this stressful situation can facilitate the students’ learning; therefore, most universities in the
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world seek to find student-centered educational methods which can lead to improvement of the
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clinical decision-making of the students (Mollahadi, 2010). A variety of methods such as

lectures, discussion in small groups, role-playing, demonstration, showing movies, and direct
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observation are used for triage education in the healthcare systems (Cottrell and McKenzie,

2010). Among these methods, the traditional method of education (lecture) is mainly verbal-

based and used commonly due to its easy implementation (Golafrooz Shahri and Khaghanizade,

2010; Salimi et al., 2007). Role-playing, an active teaching method, is another method in which

nurses play their role in an environment similar to the clinical environment and may help them to
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be prepared to face real cases in clinical settings; therefore, literature has emphasized on the role-

playing method in practical and clinical environments (Whitehair and O'Reilly, 2010).

Many studies have examined the nurses' knowledge regarding triage; some of the studies have

shown that nurses do not have sufficient knowledge about triage. A study conducted by

(Göransson et al., 2005) in Sweden showed that nurses do not receive adequate education in the

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triage area in emergency department. Another study in Iran indicated that nurses do not have

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appropriate knowledge about triage, and they had not been educated effectively (Mirhaghi and

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Roudbari, 2011). The results of a study in Australia showed that 42% of the nurses had not been

trained for triage, and 14% did not have adequate preparation for doing triage despite

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participating in the triage education classes (Fry and Burr, 2001). In Iran, triage is taught to
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nursing students only during a 2-hour session (KHATIBAN et al., 2014). Therefore, the lack of

triage education is the reason for the low knowledge of nurses about triage (Mirhaghi and
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Roudbari, 2011). Lack of triage education course in Iran has been acknowledged by the Ministry
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of Health. For this reason, according to the new guideline of Ministry of Health, triage education,

especially ESI triage, is mandatory for all triage and emergency nurses (Safari et al., 2015).
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According to the literature review, being knowledgeable about triage is an important factor in
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decision-making on triage (Considine et al., 2007; Dadashzadeh et al., 2013). Therefore,

effective educational methods should be developed and provided to improve the decision-making
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skills of the nurses. In this regard, most of the healthcare systems and faculties are seeking to

find effective educational methods which can improve clinical decision-making among health

care providers (Magnussen et al., 2000).

Studies conducted in Iran and other countries have shown lack of preparedness of nurses in

triage, leading to ineffective triage during the emergency situations (Ghanbari et al., 2011;
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Mirhaghi and Roudbari, 2011; Pishgooie and Aliyari, 2016; Schultz et al., 2012; Seyedin et al.,

2015). Lack of education regarding triage has been acknowledged by the Ministry of Health of

Iran (Ebrahimi et al., 2016), and different studies have provided different results on the accuracy

of triage by nurses (Dalwai et al., 2014; Marconi et al., 2014). Considering the overcrowded

situation and limited resources, accurate triage of patients referred to the emergency department

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is of priority (Safari et al., 2015). Therefore, it is essential to improve the nurses’ decision-

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making ability during triage in the emergency department (Al Khalaileh et al., 2012; Mirhaghi

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and Roudbari, 2011; Tabatabai et al., 2013). Since no study has been conducted regarding the

effectiveness of the educational methods in improving the nurses’ abilities in the ESI triage, this

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study was conducted to compare the effect of ESI triage education using traditional (lecture) and
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role-playing methods on the knowledge and practice of nursing students.

Methods
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DESIGN
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This study was an experimental study conducted in the Faculty of Nursing and Midwifery,

Tabriz University of Medical Sciences, Iran, in 2016.

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SAMPLE AND SETTING

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After receiving approval from the Ethics Committee of Tabriz University of Medical Sciences,

all 56 senior nursing students who had completed the “nursing crisis course” and had no
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experience of working in emergency departments signed the informed consent form and

participated in the present study. Six students were excluded from the study, and finally, the data

of 50 students were analysed. Figure 1 shows the study flowchart. First, the list of students and

their grade point average were taken from the education department. After stating the objectives

of the study to the students in the class, their informed consent for participation in the study was
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obtained, and a pre-test was answered by the participants. Then, the triage concepts were taught

to all the students in a 2-hour session using the latest version of ESI by lecture method and

PowerPoint. After educating regarding the concepts of triage, the students were matched based

on the grade point average of previous semesters and randomly allocated into two groups (lecture

or role-playing method).

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In the lecture group, scenarios adapted from the fourth edition of the guideline on ESI (Gilboy et

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al., 2012) were presented by lecture and using PowerPoint for three hours. In the role-playing

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group, the students were subjected to the scenarios using role-playing in which the other first-

semester nursing students played the role of the patients in the scenario, and they were trained to

play the role accurately.

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INSTRUMENTS

The knowledge and practice of all the students in the two groups were assessed after one month
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in the form of post-test by using a questionnaire which was developed by the researchers based
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on the latest edition of ESI triage (Gilboy et al., 2012). The questionnaire was given to 15 faculty

members of the nursing faculty, 5 emergency medicine physicians, and 5 skilled personnel of the
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emergency department in the Trauma Center of Tabriz University of Medical Sciences to

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determine the validity and reliability of the questionnaire. After conducting a study on 10 nursing

students, the reliability of the questionnaire was determined to be between 86% and 95% for the
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subgroups of the questionnaire by using Cronbach alpha coefficient. The final version of the

questionnaire consisted of three parts: a) personal and social characteristics, b) questions on

knowledge of ESI triage, and c) practice of ESI triage. The knowledge part consisted of 46

questions with 5 subgroups consisting of 1) vital signs (5 questions), 2) time (5 questions), 3)

general information on triage (5 questions), 4) facilities (11 questions), and 5) disease severity
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(20 questions). The students’ knowledge was assessed by three choices: True, 1; false, 0; I don’t

know, 0. The minimum score was 0, and the maximum score was 46. The practice part included

30 scenarios, and the choices to be selected were true, false, and I do not know (Gilboy et al.,

2012). The minimum and maximum score in this part were 0 and 30, respectively. A score of

less than 50% was considered poor, score between 50%–75% was considered moderate, and

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score above 75% was considered good.

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DATA ANALYSIS

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The collected data were analyzed using descriptive and inferential statistics such as chi-square

and independent t-test using SPSS (version 21) software. A p-value <0.05 was considered as

significant.
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Results

In this study, both groups (lecture and role-playing) were comparable in terms of age, sex,
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marital status, number of children, and students' grade point average, and there were no
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significant differences between the two groups (p > 0.05; Table 1). According to the results, the

students’ score on knowledge and practice of ESI triage improved significantly in both groups (p
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< 0.05). Moreover, the statistical test showed no significant difference in the mean total scores
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before intervention (pre-test) in the two groups (p > 0.05), but there was a significant difference

between the two groups in the post-test (p < 0.05). The mean scores of the role-playing group
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were higher than that of the lecture group (p < 0.05). In this study, the mean score of knowledge

on triage increased from 18.08% to 78.89% in the role-playing group and from 16.17% to

51.30% in the lecture group after one month. The comparisons of the mean scores in each part of

the questionnaire are shown in Table 2. The results showed that the performance score of the

students in the role-playing group increased from 17.86% to 76.93% and from 17.46 to 58.8% in
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the lecture group after the education. Taking into account the difference in the practice mean

scores, it was found that the impact of education on the practice areas in the role-playing group

(from more to less) was at the level of 2, 4, 3, 5, and 1, respectively, and in the lecture group, it

was at the level of 4, 2, 3, 1, and 5, respectively (Table 3).

Discussion and conclusion

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The results showed that the knowledge and practice scores of the students on ESI triage were less

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than 20%. This result is consistent with that of other studies conducted in Iran (Haghigh et al.,

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2017). (Tabatabai et al., 2013) and (Hedayati et al., 2013) showed that Iranian nursing students'

knowledge regarding triage was low. A study in China (Hammad et al., 2017) showed that

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almost half (50.8%) of the emergency nurses received special training on triage. The reason for
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these results could be the lack of triage courses, particularly ESI triage, for nursing students and

use of teacher-centered teaching methods. Therefore, we need to make changes in terms of the
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strategies for effective teaching methods of triage education.

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This is the first study to compare the effect of ESI triage education using traditional (lecture) and

role-playing methods on the knowledge and practice of nursing students. After education, the
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score of the nurses regarding ESI triage in the role-playing group increased up to 75% and, in the
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lecture group, increased up to 50%. A significant increase in the knowledge and practice scores

after the intervention indicates the positive impact of education by both methods. Also, the
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results showed the effectiveness of the educational program, by both educational methods, on the

level of learning in the students. This finding is consistent with the result of a study conducted by

(Kalantarimeibidi et al., 2014) in Iran. They reported that educating by conducting a workshop

has a positive impact on the knowledge and practice of ESI triage by nurses. Another study in

Iran (Haghdoust et al., 2009) investigated the effect of triage education by lecture and discussion
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method on the knowledge, attitude, and practice of nurses in an emergency department. The

results showed that the triage practice score increased from 39.7 to 55.8 after education. In our

study, we focused on ESI triage as an effective method for triage, and we showed the

effectiveness of role-playing compared with the lecture. It is noticeable that the role-playing

method has been mentioned as an effective method in nursing education (Yu and ja Kang, 2017).

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(Sarikaya et al., 2004) from Turkey reported the positive effect of one training session on the

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triage decisions made by the emergency physicians. A study in Italy showed that the

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development of educational courses had a positive impact on the quality of students' skill on

triage (Parenti et al., 2013). In general, the results of this study are in line with the results of

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other studies which emphasize the role of education on knowledge and practice of triage.
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Moreover, the positive effect of triage education in this study could be related to the use of the

context-based triage scenario, providing the objective experiences of triage, and free discussion
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of students in both role-playing and lecture groups.

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The results of this study showed a significant difference between the two educational methods,

and the impact of the role-playing method was more than that of the lecture method on the ESI
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triage. This result is in line with a randomized controlled trial conducted by (Sato et al., 2017) in
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Japan; they showed that the role-playing method was more effective than the illustration method

in hazard prediction training in nursing students. Another quasi-experimental study

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(Chaharsoughi et al., 2014) in Iran showed that role-play is more effective than a lecture in

teaching SBAR technique (Situation-Background- Assessment- Recommendation) to nurses.

However, in a study conducted by (Tadrisi et al., 2011) in Iran, the nurses’ learning about triage

increased by both educational methods (lecture and multi-media method), and there was no

significant difference between the two methods. The results of a study by (Aghababaeian et al.,
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2013) showed that both role-playing and educational video had a positive impact in increasing

the knowledge and practice of the emergency medical technicians. They proposed that role-

playing may have more desirable and more stable impact on triage practice. This study was

conducted among emergency medical technicians while we studied the nursing students.

In a study conducted by (DeNeve and Heppner, 1997) in the USA, it was reported that role-

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playing method is more interesting and effective than the lecture method. Moreover, in a study

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conducted by (Knowles et al., 2001) in the UK, the results showed that video role-play with

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structured feedback could improve the communication skills of medical students. (Dubovsky et

al., 2017) from the USA reported that computerized simulation is a good method for educating

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ED nurses regarding triage. In this regard, (Redden, 2015) has emphasized the importance of
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combining role-playing and simulation in nursing education.

The findings of this study and other studies in this area reveal the importance of the educational
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method in which the interactions between the learner and trainer are more. It seems that
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combining the interactive educational methods can improve the learning of students. In our

study, the reasons for the effectiveness of role-playing compared with the lecture method may be
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related to the simulated environment of triage in practice, the interaction between the learners,
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patients, and the trainer, and active participation of the learners and the interesting nature of the

role-playing in triage.
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The results of this study showed that the impact of education on the knowledge of the

participants in both role-play and lecture groups was somewhat similar. Although triage is a

practical act, we cannot perform actions without having good knowledge (Lugt‐Lustig et al.,

2014; Mousavi et al., 2011). Moreover, the results showed that in the practice areas, the greatest

impact in the role-playing group was at the level 2 triage, whereas in the lecture group, the
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greatest impact was at the level 4 triage. Nurses examine life-threatening conditions (cyanosis,

respiratory distress, and signs of shock) at the ESI triage level 1 and high-risk conditions (severe

pain or distress, drowsiness) at the ESI triage level 2, and then places the patients at level 1 or 2

based on these signs and symptoms (Gilboy et al., 2012). If the triage nurse mistakenly does not

observe these signs or symptoms in the patient, she or he may over-triage or under-triage, which

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can be risky for the patients who are at this level according to the priority of the need for life-

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saving measures. (Turégano-Fuentes et al., 2008). In a cohort study conducted by (Hinson et al.,

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2018) in Brazil, the results showed that despite precise and constant training of ESI users, a large

number of patients were under- or over-triaged. Therefore, if the educational methods can help

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the nurses in identifying life-threatening cases better, they will be more beneficial; it seems that
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the role-playing method can be helpful in this regard.

The results of this study showed the effectiveness of both educational methods on students'
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learning. However, the role-playing method was more effective than the lecture method, and the
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former method can be recommended for triage education among nursing students. Using

interactive educational methods such as role-playing could be useful for skills education related
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to the nurses’ practice such as triage education. Also, according to the importance of triage,
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developing the theoretical and practical education courses is recommended for nursing students.
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Limitations:

The present cross-sectional study was limited to senior nursing students to avoid interfering with

the curricula of the faculty; so it is recommended that the triage curriculum should be developed

for the large numbers of students at different educational semesters and in nursing clinic and

practice (emergency department). Moreover, a longitudinal study is recommended for assessing

the retention of triage learning among the students.

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Conflict of interest:

There is no conflict of interest in this study.

Acknowledgement:

This project was derived from the master's thesis conducted in Tabriz faculty of Nursing and
Midwifery. Hereby, the authors appreciate all students who participated in this study.

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Table 1- Characteristics of subjects

Variable Role playing group (n=25) Lecture group (n=25) p- value

N (%) Mean (SD) N (%) Mean (SD)

Age 25(50) 21.84(2.32) 25(50) 21.84(1.51) P= 1.000

Gender male 13(52) 12(48) P= 1.000

Female 12(48) 13(52)

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Marital status single 20(80) 24(96 P= 0.095

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Married 5(20) 1(4)

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High school average score 25(50) 18.29(1.38) 25(50) 17.82(1.43) P= 0.248

Average of 6 semesters in 25(50) 16.26(0.90) 25(50) 15.73(1.34) P= 0.114

university

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Table 2- Score of nursing students’ knowledge in Emergency Severity Index (ESI) triage
in both groups before and after education
Variables Groups Statistical tests
related to Role playing group Lecture group Pre-test Post-
knowledge Mean (SD) Mean (SD) test
of ESI triage Pre-test post-test Pre-test post-test

knowledge 8.32(6.30) 36.24(3.32) 7.44(5.42) 23.60(5.21) t=0.529 t=

of triage p= 0. 10.227
(total) 599 p=

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Domains
Vital signs 0.760(0.778) 4.040(0.675) 0.600(0.763) 2.560(1.260) t= 0.733 t= 5.173
p= 0.467 p=

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0.000
Time 1.64(1.845) 4.000(1.000) 1.280(1.458) 3.200(1.190) t= 0.765 t= 2.573
p= 0.448 p=
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General 0.120(0.439) 4.440(0.711) 0.160(0.472) 2.760(1.300) t= 0.310 t= 5.668
questions p= 0.758 p=
0.000
Facilities 1.480(1.981) 8.760(1.507) 1.240(1.786) 6.040(2.589) t= 0.450 t= 4.538
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p= 0.655 p=
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Severity 15.000(1.47) 4.360(2.998) 4.240(2.919) 9.040(2.318 t= 0.143 t=
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p=
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Table 3- Practice score of nursing students in Emergency Severity Index (ESI) triage in
Role playing and Lecture groups before and after education

Variables groups Mean (SD) Statistical tests

related to Role playing group Lecture group Pre-test Post-test
practice of ESI Pre-test post-test Pre-test post-test
triage
Practice of 5.36(3.10) 23.08(2.69) 5.24(2.78) 17.64(4.73) t= 0.144 t= 4.995

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triage (total) p= 0.886 p= 0.000

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practice
subgroups

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Level 1 2.120(1.615) 5.480(1.557) 1.560(1.416) 4.080(1.469) t= 1.303 t= 3.269
p= 0.199 p= 0.002
Level 2 0.560(0.768) 0.640(0.810) 4.120(1.563) t= 0.358 t= 3.100

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5.440(1.44) p= 0.722 p= 0.003
Level 3 1.320(1.281) 6.680(1.547) 1.640(1.254) 1.520(1.828) t= - 0.892 t= 2.422
p= 0.377 p= 0.019
Level 4 0.440(0.650) 2.480(0.653) 0.520(0.714) 2.120(0.927) t= -0.414 t= 1.587
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p= 0.681 p= 0.119
Level 5 0.920(0.702) 0.880(0.725) t= 0.198 t= 3.928
3.000(1.040) 1.800(1.118) p= 0.844 p= 0.000
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Figure 1. Flow chart of the study O
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Last year nursing students before N
start of study (n=56) T

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A
Pre-test of students L
2 students did not participate in L

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pre-test O
3 students did not participate in C
triage education Educating ESI triage concepts A
(n=50) for two hours
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One person was excluded I
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Randomizing (n=50)
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Role playing group (n=25) Lecture group (n=25)
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Educating of triage scenarios (30 scenario) based on Educating of triage scenarios (30 scenario) based on ESI
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ESI triage for three hours by role playing method triage for three hours by lecture U
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One A
month N
Post-test (n=25) A
Post-test (n=25) L
Performing post-test Y
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Analysis (n=25) rooms
Analysis (n=25) S
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Highlights

 Emergency nurses in Iran have difficulties in doing triage in emergency situations.

Therefore, Training of this groups is in priority of Ministry of Health.

 Nurse educators could find an effective method for educating of triage in a practical way

which improves nursing students’ knowledge and practice.

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 Role playing method as a practical method could help nurse students to learn the triage in

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an effective way.

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