Competency Level of Triage Nurses in Emergency Departments of Hospitals in the 5th District of Camarines Sur

Introduction

The global crisis in emergency care is heavily impacted by low international triage accuracy rates, which average only 59% (Emergency Nurses Association, 2024). This performance deficit highlights an urgent need for enhanced competency development programs, especially given the unpredictable, highly distracting, and resource-strained nature of emergency departments (Emergency Nurses Association, 2024). In the Philippines, these challenges manifest as chronic overcrowding, prolonged waiting times, and limited specialized training opportunities for emergency nurses, which directly compromise patient safety and departmental efficiency (Comia et al., 2022).

To govern and elevate nursing practice, the Philippine healthcare system relies on key legislative frameworks. Republic Act No. 9173 (The Philippine Nursing Act of 2002) mandates that professional nurses maintain advanced assessment and decision-making skills through continuing professional development. Furthermore, Republic Act No. 8344 legally obligates healthcare facilities to provide immediate emergency treatment regardless of a patient's ability to pay, legally requiring competent triage nurses to avoid criminal penalties. Concurrently, Republic Act No. 11223 (The Universal Health Care Act of 2019) has transformed the national health system by setting strict facility licensing standards, though specific, enforceable competency metrics for triage staff remain under development (Universal Health Care Act, 2019).

At the local level, the 5th District of Camarines Sur and Iriga City exemplify these systemic vulnerabilities due to severe nursing shortages and a reliance on rotating general staff into triage roles without specialized training. Rather than comprehensive, simulation-based training, nurses frequently receive only brief orientations, resulting in inconsistent protocol applications and heightened stress when making high-stakes decisions. The lack of standardized assessment tools and quality monitoring leaves competency gaps unaddressed, while community cultural pressures further complicate clinical prioritization. Consequently, localized infrastructure improvements are overshadowed by a critical need for formal triage training, objective performance metrics, and systematic quality oversight to ensure equitable and safe emergency care.

Methodology

The study analyzed the collected data using a quantitative descriptive research design. Quantitative research is a methodical approach that uses numbers to analyze data and uncover patterns, relationships, and trends. It helped researchers reach objective conclusions and make informed decisions (Researcher Life, 2025).

Descriptive research is a type of quantitative research that aims to accurately and systematically describe the characteristics of a population, situation, or phenomenon. This study employed a research approach to assess the competence of triage nurses working in emergency departments at hospitals in the 5^th District of Camarines Sur.

The respondents of the study were the triage nurses on rotation in the emergency departments at 5^th District of Camarines Sur Hospitals, namely: Our Lady Mediatrix Hospital (7), Villanueva-Tanchuling Hospital (5), Sta. Maria Josefa Hospital Foundation, Inc., (10), CHMSC Lourdes Hospital (7), and Medical Mission Group Hospital (7). Total enumeration was employed through the purposive sampling method. The total number of respondents was 36 nurses.

In gathering the data, the researcher used a questionnaire checklist. The responses were systematically sorted and tabulated quantitatively using statistical instruments such as frequency counts, percentages, weighted mean, and the chi-square test.

Results and Discussion

Profile of the Respondents

Table 1 presents the profiles of the 36 triage nurse respondents from emergency departments in hospitals within the 5^th District of Camarines Sur. The profile covers age, sex, civil status, highest educational attainment, designation, length of service, seminars/training related to emergency/triage nursing, and frequency of continuing education sessions.

Age. The respondents are predominantly in the younger age brackets, with the largest group falling between 26–30 years old with 10 or 27.78%, followed by 20–25 years old with nine or 25.00%, 41-45 years old with six or 16.66%. Respondents who are 31-35 years old and 36-40 years old got five or 13.89%. Only one or 2.78 percent were 51 years old and above.

Sex. The respondents are predominantly females, consisting of 24 or 66.67%, while there are only 12 or 33.33% males.

Civil Status. More than half of the respondents are single with 21 or 58.33%, while the remaining 15 or 41.67% of the respondents are married.

Highest Educational Attainment. The vast majority of the respondents have a Bachelor of Science in Nursing (BSN) as their highest qualification, with 35 or 97.22%. Only 1 or 2.78% holds a Diploma in Nursing. None of the respondents reported having a Master's degree, a Doctorate, or any other special certifications.

Designation. Out of 36 respondents, 31 or 86.11% are Staff Nurses, while three or 8.33% are Senior Staff Nurses. There is one or 2.78% Charge Nurse (2.78%) and one or 2.78% Head Nurse/Nurse Supervisor.

Length of Service. The largest group of respondents has served for 1-3 years with 12 or 33.34%, followed by those with 4-6 years of service with 8 respondents or 22.22%. Six respondents or 16.67% have less than one year of experience, while four or 11.11% have more than 15 years. The 7-10 years and 11-15 years groups both consist of three respondents or 8.33% each.

Seminars and Training Related to Emergency/Triage Nursing. Respondents reported a total of 80 training attendances. The most common certifications are Basic Life Support (BLS) with 35 attendances or 43.75% and Advanced Cardiac Life Support (ACLS) with 28 or 35.00%. Other trainings include Disaster Preparedness (seven or 8.75%), Trauma Nursing Core Course (three or 3.75%), and Mass Casualty Incident training (three or 3.75%). Pediatric Advanced Life Support (PALS) had two attendances (2.50%), while Emergency Nursing Pediatric Course (ENPC) and Pain Management each had one (1.25%).

Frequency of Training or Continuing Education. Over half of the respondents with 20 or 55.56% attend training 1-2 times per year. Nine respondents or 25.00% reported having attended no sessions in the past year, and seven or 19.44% of the respondents attend 3-4 times per year.

The profile reveals respondents that is largely young, early-career, predominantly female, and BSN-prepared, characteristics typical of nursing workforces in provincial Philippine hospitals. The absence of any nurse with a master's degree and the complete lack of triage-specific training are notable gaps. While BLS and ACLS provide foundational emergency competencies, they do not directly address the systematic decision-making frameworks essential to triage, such as the Emergency Severity Index (ESI) or the Philippine START/SALT triage protocols. The low training frequency further suggests limited institutional investment in continuing professional development, which is a critical concern in emergency nursing, where protocols evolve rapidly.

Alobo et al. (2023) found that in resource-limited hospital settings in Southeast Asia and sub-Saharan Africa, the majority of emergency nurses are BSN-prepared, have less than 5 years of ED experience, and have not undergone formal triage-specific training, relying instead on general emergency life support certifications. This misalignment between training content and triage function was identified as a systemic gap in emergency preparedness. Similarly, Andersson et al. (2022) documented that nurses who attend continuing education fewer than three times per year demonstrate significantly lower competency scores in triage decision-making compared to those attending more frequently, underscoring the need for structured, regular triage-focused professional development programs in hospital systems.

Competency Level of Triage Nurses in Emergency Departments of Hospitals in the 5^th District of Camarines Sur

The following table shows the competence level of triage nurses in emergency departments of hospitals in the 5^th District of Camarines Sur in assessing and effectively prioritizing patients, along with skills, knowledge, and attitudes.

Skills. Table 2 presents the competency level of triage nurses in emergency departments of hospitals in the 5^th District of Camarines Sur in assessing and effectively prioritizing patients, along skills.

Based on the result, the competency level of nurses is very high in accurately assessing patients' vital signs quickly and efficiently (4.56), skillfully communicating with patients and families (4.44), effectively identifying life-threatening conditions (4.42), and coordinating effectively with the emergency department team (4.33).

Moreover, the nurses have high degree of competency along appropriate use of triage assessment tools (4.19), efficient documentation (4.19), recognition of subtle signs of clinical deterioration (4.19), patient reassessment (4.17), and rapid physical examinations (4.11). Overall, the competency level of nurses along skills is very high, with an average mean of 4.29.

The very high overall rating of skills reflects that triage nurses in the 5^th District of Camarines Sur have a strong foundation in the most critical, time-sensitive clinical functions: vital-sign assessment, identification of life-threatening conditions, and communication. These skills are the frontline competencies most frequently practiced and reinforced in daily emergency department work, which likely explains their high ratings. However, the relatively lower scores for documentation accuracy, reassessment of waiting patients, and recognition of subtle deterioration signals suggest areas where skill proficiency, while still good, may benefit from more deliberate reinforcement. These are precisely the skills that require systematic training rather than purely experiential learning, documenting within structured triage frameworks and recognizing early warning signs demand formal protocol knowledge, not just bedside practice.

The dominance of vital sign assessment and communication as top-ranked skills is consistent with findings from Göransson and von Rosen (2022), who identified that triage nurses across multiple emergency settings consistently rate cardiovascular and respiratory assessment competencies highest, as these are the skills most directly practiced in daily clinical encounters and most closely tied to nurse identity in emergency care. However, their study also warned that high self-rated skill scores do not always correlate with objective measures of competency, calling for structured evaluations beyond self-report. Additionally, Wolf et al. (2023) found that documentation completeness and patient reassessment frequency are the two skill domains most often cited as deficient in triage audits across district-level hospitals, attributing this to high patient volume, time pressure, and the absence of standardized electronic triage documentation systems, conditions highly applicable to the 5^th District of Camarines Sur.

Knowledge. Table 3 discusses the competency level of triage nurses in emergency departments of hospitals in the 5^th District of Camarines Sur in assessing and effectively prioritizing patients, along knowledge.

The nurses’ competency level in terms of knowledge is very high in understanding the principles of pain assessment and management in emergency settings (4.25) and knowledgeable on cultural sensitivity (4.22), while the competency level of nurses is high on familiarity of legal and ethical considerations (4.17), knowledge of triage categories and priority levels (4.14), infection control protocols (4.11), pharmacology relevant to emergencies and disaster/mass-casualty triage protocols (4.06), pathophysiology of common emergency conditions, staying updated with evidence-based practices (4.03), and pediatric emergency presentations and age-specific assessment criteria (3.89). The overall competency level of nurses in knowledge is high, with an average of 4.09.

The knowledge competency level reveals strengths in clinically applied domains, particularly pain management and cultural sensitivity, both of which are embedded in day-to-day patient interactions and reinforced through practical experience. The relatively low score on the pediatric emergency assessment is a clinically important gap: pediatric triage requires specialized knowledge of age-specific vital-sign parameters, weight-based dosing, and developmentally appropriate communication, none of which is adequately covered in general BLS or ACLS training. The uniformity of Very Competent ratings across most items also warrants critical reflection, given that no respondent holds a post-baccalaureate degree and triage-specific training was absent; the knowledge base may be largely experiential rather than theory-grounded, which could limit application in novel or complex emergency scenarios.

Baharoon et al. (2022) found that triage nurses without specific Pediatric Advanced Life Support (PALS) or Emergency Nursing Pediatric Course (ENPC) certification consistently underperform in pediatric acuity categorization, leading to higher rates of under-triage in pediatric patients a potentially life-threatening error. In the present study's profile data, only 2 of 36 nurses (5.56%) have attended PALS training, a proportion far below the recommended coverage. Furthermore, Lavoie et al. (2023) documented that self-assessed knowledge scores in emergency nurses tend to be inflated relative to objective knowledge test performance, a phenomenon particularly pronounced among nurses with 1–5 years of experience who may overestimate their theoretical knowledge base, a profile that matches the majority of this study's respondents.

Attitudes. Table 4 presents the competency level of triage nurses in the emergency departments of hospitals in the 5^th District of Camarines Sur in assessing and effectively prioritizing patients, along attitudes.

The nurses' competency level, along with attitudes, is very high, with a strong belief that ethical principles prevent bias in patient prioritization decisions (4.42), motivation to stay updated on triage protocols through continuous training (4.33), acceptance of full accountability for triage errors and advocacy for better resources (4.31), and collaborating with the emergency team (4.22). Additionally, the nurses have a high degree of competency, including actively seeking feedback (4.19), empathy guiding patient interactions (4.14), prioritizing patient safety (4.11), remaining calm during high-volume surges (4.06), and feeling confident in making independent triage decisions under pressure (3.97).

The overall average mean of 4.21 indicates that triage nurses have a high competency level along attitudes.

The attitudinal profile is largely positive, suggesting that triage nurses in the 5^th District of Camarines Sur have a strong ethical foundation and a genuine commitment to professional development. The highest-rated item, ethical prevention of bias, is particularly meaningful in the Philippine context, where socioeconomic disparities, VIP culture in healthcare facilities, and personal relationships can sometimes influence clinical prioritization. The lowest-rated item, confidence in making independent triage decisions under pressure, is a critical finding. Low decisional confidence in high-stakes, time-compressed environments is a known precursor to triage errors and decision avoidance. Despite strong ethical values, if a nurse hesitates to act independently under pressure, patient outcomes may be compromised.

The finding that ethical commitment scores highest while decisional self-confidence scores lowest is consistent with patterns identified by Tumpey et al. (2022), who found that emergency nurses in under-resourced settings report strong professional values but significantly lower confidence in autonomous decision-making, attributing this to organizational cultures that emphasize physician-led decision hierarchies over nurse-led triage authority, a pattern common in Philippine government hospitals. This creates what the authors termed a "values-action gap," where strong ethical intent does not automatically translate into confident clinical action. Relatedly, Shokati Ahmadabad et al. (2023) found in a study of emergency nurses in low-to-middle-income country hospitals that professional attitude scores were the strongest predictor of overall triage competency, but only when attitudinal confidence not just values was high, suggesting that confidence-building interventions are as important as ethical formation in triage education programs.

Test of Significant Relationship between the Profile and the Competency Level of Triage Nurses in Emergency Departments of Hospitals in the 5^th District of Camarines Sur

Table 5 presents the results of chi-square (X²) test examining the relationship between eight profile variables and the overall competency level of triage nurses emergency departments of hospitals in the 5^th District of Camarines Sur. Each variable is tested at a specified degree of freedom (df), with a corresponding X² computed value, tabular value, and decision on the null hypothesis (H_o) and interpretation. The significance level used is α = 0.05.

The result of statistical data showed that age, sex, civil status, highest educational attainment, designation, length of service, seminars/training related to emergency/triage nursing and frequency of training or continuing education sessions attended with a computed values of 0.42, 0.08, 0.12, 0.01, 0.28, 0.55, 0.01, 0.15 were lesser than the tabular value of 36.415, 9.488, 26.296, 26.296, 26.296, 31.410, 45.231 and 26.296, respectively at 0.05 level of significance, therefore the null hypothesis is accepted. This implies that age, sex, civil status, highest educational attainment, designation, length of service, seminars/training related to emergency/triage nursing, and frequency of training or continuing education sessions attended do not have any significant relationship with the competency level of triage nurses in the emergency department.

The uniformly non-significant results are both statistically and clinically thought-provoking. At first glance, one might expect that length of service, designation, or training frequency would significantly predict competence. The absence of such relationships may be attributable to several factors: the relatively homogeneous profile of the respondents (predominantly BSN-prepared Staff Nurses with similar training backgrounds), the small sample size of 36, which limits statistical power to detect meaningful differences, and the possibility that self-rated competency rather than objective performance tends to level out across demographic groups. It is also possible that in the 5^th District of Camarines Sur emergency departments, nurses at all levels are exposed to similar clinical volumes and learning environments, resulting in comparable competency self-perceptions regardless of their individual profiles.

The finding that demographic and experiential variables do not significantly predict triage competence aligns with results from Khorram-Manesh et al. (2022), who found in a multicenter study of emergency department nurses that neither age, years of experience, nor educational level significantly predicted triage accuracy scores, suggesting that contextual factors such as institutional protocols, supervision quality, and triage system design exert stronger influence on competency than individual nurse characteristics. However, the lack of significance of training frequency in this study contrasts with international findings. Göransson et al. (2023) demonstrated that nurses who participated in structured triage simulation training at least three times annually showed significantly higher objective triage accuracy compared to those with lower or no formal training frequency, a discrepancy that may reflect the difference between structured, simulation-based training and the informal, lecture-based continuing education typical of provincial Philippine hospital settings.

Impact of Triage Nurses’ Competency on Patients

The succeeding table shows the impact of the triage nurses’ competency on patients along waiting time, quality of care and outcomes.

Waiting Time. Table 6 evaluates the perceived impact of triage nurse competency on patient waiting time. All indicators are rated very high impact along patient waiting time, with an average weighted mean is 4.38,

The top indicator, with very high impact, was effective communication during triage, which streamlines patient flow through the department (4.47). followed by competent triage assessment reduces overall patient waiting time, efficient triage processes minimize delays in initial patient evaluation and proper triage decisions prevent unnecessary waiting for high-acuity patients (WM = 4.44). Other indicator with very high impact include accurate prioritization, ensuring critical patients receive immediate attention (4.39), skilled triage assessment, contributing to overall ED efficiency (4.39), and timely reassessment, preventing deterioration and prolonged waits (4.33) and appropriate resource allocation to reduce bottlenecks (4.22).

Respondents strongly affirm that their competence directly reduces patient waiting time, with communication-driven patient flow rated as the most impactful element. This is clinically coherent: in a triage system, communication determines how quickly and accurately a patient's acuity is conveyed to the treatment team, directly governing how fast the patient moves through the department. The slightly lower rating for resource allocation reflects a realistic recognition that bottlenecks in the emergency department are not solely determined by triage nurses’ competence; they are also driven by physician availability, bed capacity, and departmental infrastructure that lie outside nurses' control.

The strong association between triage nurse competence and reduced waiting time is well supported by current evidence. Weston et al. (2022) found in a prospective cohort study across multiple emergency departments that higher triage nurse competency scores were independently associated with a 23% reduction in mean door-to-physician time, with communication accuracy identified as the strongest mediating factor, directly echoing this study's top-ranked indicator. Additionally, Andersson et al. (2023) demonstrated that emergency departments with nurses who scored above the 75th percentile on triage competency assessments reported significantly shorter mean length of stay for low-to-moderate acuity patients, attributing this to more accurate initial categorization, which prevents overutilization of high-acuity resources and reduces downstream waiting cascades.

Quality of Care. Table 7 presents the impact of triage nurse competency on quality of care. All indicators are interpreted as very high impact with an average weighted mean of 4.44.

There is a very high impact on triage nurse competency, which comprehensive triage documentation supports quality patient care and. safety (4.50), competent triage assessment, leading to appropriate and timely interventions, effective triage communication, ensuring continuity of care and competent triage nursing, positively impacting overall emergency department performance metrics (4.47), prioritization, preventing patient deterioration (4.44), thorough initial assessment, improving diagnostic accuracy, competent nurses contributing to higher patient satisfaction and skilled assessment that reduces medical errors (4.42), reducing the risk of adverse outcomes and improving resource utilization and cost-effectiveness (4.39).

The quality-of-care domain received the highest average weighted mean among all impact dimensions, indicating that respondents most strongly perceive their competence as affecting care quality rather than wait times or outcomes alone. The primacy of documentation as the top indicator is particularly significant it suggests that nurses recognize accurate record-

keeping not merely as an administrative function but as a patient safety mechanism. This awareness is clinically mature and aligns with current quality improvement frameworks that position documentation as the cornerstone of continuity and error prevention in emergency care. The relatively lower scores for cost-effectiveness reflect the reality that nurses at the bedside may feel more remote from the financial and operational consequences of their decisions compared to the direct clinical impact they observe daily.

The relationship between triage competence and quality of care is well-established. Considine et al. (2022) demonstrated in a retrospective analysis of Australian emergency departments that nurse-led triage with high documentation fidelity was associated with a 31% reduction in unplanned patient re-presentations within 48 hours a direct quality-of-care outcome attributable to the completeness of the initial triage record informing downstream care decisions. The primacy of documentation in this study's findings directly parallels this evidence. Furthermore, Göransson et al. (2023) established that triage accuracy, defined as correct acuity assignment, is the single strongest predictor of avoided adverse events in emergency settings, with each triage category error associated with a measurable increase in the probability of clinical deterioration, supporting the respondents' strong agreement that competent triage reduces adverse outcomes.

Outcomes. Table 8 presents ten outcome-related indicators reflecting the perceived impact of triage nurse competency on patient outcomes. All ten indicators have a very high impact, with an average weighted mean of 4.37.

The highest-ranked indicator, which has a very high impact, was enhanced team coordination resulting from clear triage communication (4.47), followed by accuracy in identifying life-threatening conditions during initial assessment and overall improvement in emergency department performance (4.42), compliance with national triage standards (4.39), reduction in patient wait times for high-acuity cases, fewer incidents of mis-prioritization, improved patient satisfaction, and effective resource allocation during peak hours (4.36), successful re-triage adjustments for changing patient conditions (4.31), and lower rates of preventable complications post-triage (4.28).

The findings reflect a strong self-perceived impact of triage competence on patient outcomes. The top-ranked outcome is team coordination through clear communication. Communication is consistently recognized as the most powerful competency-linked lever for improving emergency care at every level, from reducing wait times to enhancing outcomes. The lower rating for preventable complications post-triage is clinically honest it acknowledges that post-triage outcomes are influenced by a wide chain of clinical events beyond the triage nurse's direct control, including treatment decisions, resource availability, and physician response time. This nuanced self-assessment reflects a sophisticated understanding of the triage nurse's scope of impact within the broader aspect.

Team coordination via communication is the highest-impact outcome indicator is supported by Nordin et al. (2022), who found in a mixed-methods study of emergency nurses in Scandinavian and Southeast Asian settings that interprofessional communication quality during triage handover was the strongest predictor of positive patient outcomes, outperforming individual nurse competency metrics, reinforcing that triage competence operates not in isolation but as a team-embedded function.

The findings from Rortveit et al. (2023) who documented that hospitals with structured triage nurse competency development programs reported significantly better patient outcome indicators including reduced in-ED mortality rates, lower rates of mis-triage, and higher patient satisfaction scores, compared to hospitals relying solely on on-the-job triage learning, affirming the critical link between deliberate triage competence development and measurable patient outcomes in emergency settings.

Measures can be proposed to Improve Triage in the Emergency Departments of hospitals in the 5^th District of Camarines Sur to Enhance Patient Safety and Care Efficiency

The data gathered from triage nurse respondents in hospitals' emergency departments in the 5th District of Camarines Sur reveal several compelling reasons for developing a structured Triage Competency Development Program. None of the respondents attended any triage-specific training program, despite triage being their primary clinical function. While the majority hold BLS and ACLS certifications, these do not adequately address the systematic decision-making frameworks essential to triage.

Knowledge emerged as the weakest competency, compared to skills and attitudes, with pediatric emergency assessment scoring the lowest among all indicators. This is particularly alarming, given that only 2 of 36 nurses (5.56%) have completed PALS training, far below the recommended coverage level. Moreover, 25% of respondents attended no continuing education in the past year, and none exceeded 3 to 4 sessions annually, reflecting limited institutional investment in professional development. The lowest-rated attitudinal indicator was decisional confidence under pressure, suggesting a critical values-action gap in which strong ethical commitment does not automatically translate into confident, autonomous clinical action. Documentation accuracy and patient reassessment were also identified as relatively weaker skill areas, consistent with international findings citing these as the most frequently deficient domains in triage audits of district-level hospitals.

The Triage Competency Development Program aims to develop and implement a structured, competency-based training initiative that bridges the identified gaps in triage nurses' knowledge, reinforces critical skills in documentation and patient reassessment, and builds decisional confidence in high-pressure clinical environments. Through this program, the emergency departments of hospitals in the 5th District of Camarines Sur seek to cultivate a triage nursing workforce that is not only ethically committed but also theoretically grounded and clinically confident, ultimately improving patient safety, reducing waiting times, and enhancing the overall quality of emergency care.

Conclusion

The majority of the respondents are females, single, have attained a Bachelor of Science in Nursing (BSN), are staff nurses, have attended continuing education sessions 1-2 times, and have training in Basic Life Support. Most respondents are 26-30 years old and have served for 1-3 years. The respondents have a very high competency level in the emergency departments of hospitals in the 5^th District of Camarines Sur, along with skills and attitudes, and a high competency level in knowledge. The profile of the respondents in terms of age, sex, civil status, highest educational attainment, designation, length of service and seminars/training related to emergency/triage nursing and frequency of training or continuing education sessions attended has no significant relationship with their competency level in emergency departments of Hospitals in the 5^th District of Camarines Sur. There is a very much high impact on the competency level of triage nurses along with waiting time, quality of care, and outcome. The Triage Competency Development Program could be proposed to improve triage in the emergency departments. of hospitals in the 5^th District to enhance patient safety and care efficiency.