Assessing the feasibility of an education intervention for triage interruption managementAbstract
Objective To develop and evaluate a simulation-based learning (SBL) intervention specifically designed to prepare triage nurses for effective interruption management.
Methods A quasi-experimental, two-group design was used to assess feasibility and preliminary outcomes. Thirty-four triage nurses from an academic emergency department participated; 14 were assigned to the intervention group, receiving a one-time SBL session focused on managing interruptions, while 20 served as controls. Two weeks post-intervention, blinded observers assessed participants in real-time triage using a validated tool measuring proficiency, interruption duration, and triage time. Participant perceptions of simulation fidelity were also collected. Data analysis included traditional regression and regression tree modeling to explore predictors of proficiency. STROBE checklist was completed.
Results Although participants rated the simulation scenarios as highly realistic (M = 8.14, SD = 1.70), participants requested more preparatory information prior to simulation. No statistically significant differences were observed between groups in triage duration or proficiency. However, regression tree analysis revealed important patterns: nurses experiencing interruptions under 15 seconds demonstrated the highest proficiency regardless of training, while those with less than 4.8 years of experience and interruptions over 15 seconds had the lowest scores. These findings suggest interruption duration and experience may have stronger influences on triage performance than the intervention alone.
Conclusion This SBL intervention was feasible and well received. While no significant performance improvements were found, the study highlights key contextual variables—interruption duration and clinical experience—that may shape future training impact. These results support further refinement and larger-scale testing of structured interruption management education for triage nurses.
Keywords:
Triage; Patient safety; Checklist; Feasibility studies; Emergency nursing; Emergency service hospital
Resumo
Objetivo Desenvolver e avaliar uma intervenção de aprendizagem baseada em simulação (SBL) projetada especificamente para preparar enfermeiros de triagem para o gerenciamento eficaz de interrupções.
Métodos Um desenho quase experimental com dois grupos foi usado para avaliar a viabilidade e os resultados preliminares. Trinta e quatro enfermeiros de triagem de um departamento de emergência acadêmico participaram; 14 foram designados para o grupo de intervenção, recebendo uma sessão única de SBL focada no gerenciamento de interrupções, enquanto 20 serviram como controles. Duas semanas após a intervenção, observadores cegos avaliaram os participantes em triagem em tempo real usando uma ferramenta validada que mede a proficiência, a duração da interrupção e o tempo de triagem. As percepções dos participantes sobre a fidelidade da simulação também foram coletadas. A análise de dados incluiu regressão tradicional e modelagem de árvore de regressão para explorar preditores de proficiência. A lista de verificação STROBE foi preenchida.
Resultados Embora os participantes tenham classificado os cenários de simulação como altamente realistas (M = 8,14, DP = 1,70), eles solicitaram mais informações preparatórias antes da simulação. Não foram observadas diferenças estatisticamente significativas entre os grupos na duração da triagem ou na proficiência. No entanto, a análise da árvore de regressão revelou padrões importantes: os enfermeiros que sofreram interrupções inferiores a 15 segundos demonstraram a maior proficiência, independentemente do treinamento, enquanto aqueles com menos de 4,8 anos de experiência e interrupções superiores a 15 segundos tiveram as pontuações mais baixas. Esses achados sugerem que a duração da interrupção e a experiência podem ter influências mais fortes no desempenho da triagem do que a intervenção por si só.
Conclusão Esta intervenção SBL foi viável e bem recebida. Embora não tenham sido encontradas melhorias significativas no desempenho, o estudo destaca variáveis contextuais importantes — duração da interrupção e experiência clínica — que podem moldar o impacto do treinamento futuro. Esses resultados apoiam o aprimoramento e o teste em maior escala da educação estruturada em gerenciamento de interrupções para enfermeiros de triagem.
Descritores:
Triagem; Segurança do paciente; Lista de checagem; Estudos de viabilidade; Enfermagem em emergência; Serviço hospitalar de emergência
Resumen
Objetivo Desarrollar y evaluar una intervención de aprendizaje basada en la simulación (SBL) diseñada específicamente para preparar al personal de enfermería de triaje para la gestión eficaz de las interrupciones.
Métodos Se utilizó un diseño cuasi-experimental con dos grupos para evaluar la viabilidad y los resultados preliminares. Participaron treinta y cuatro enfermeros de triaje de un servicio de urgencias académico; catorce fueron asignados al grupo de intervención, donde recibieron una única sesión de SBL centrada en la gestión de interrupciones, mientras que veinte actuaron como grupo de control. Dos semanas después de la intervención, observadores ciegos evaluaron a los participantes durante el triaje en tiempo real utilizando una herramienta validada que mide la competencia, la duración de la interrupción y el tiempo de triaje. También se recabaron las opiniones de los participantes sobre la fidelidad de la simulación. El análisis de datos incluyó regresión tradicional y modelización de árbol de regresión para explorar los factores predictivos de la competencia. Se completó la lista de verificación STROBE.
Resultados Aunque los participantes calificaron los escenarios de simulación como muy realistas (M = 8,14; DP = 1,70), solicitaron más información preparatoria antes de la simulación. No se observaron diferencias estadísticamente significativas entre los grupos en cuanto a la duración de la clasificación ni a la competencia. Sin embargo, el análisis del árbol de regresión reveló patrones importantes: los enfermeros que sufrieron interrupciones inferiores a 15 segundos mostraron la mayor competencia, independientemente de la formación, mientras que aquellos con menos de 4,8 años de experiencia e interrupciones superiores a 15 segundos obtuvieron las puntuaciones más bajas. Estos hallazgos sugieren que la duración de la interrupción y la experiencia pueden influir más en el rendimiento del triaje que la intervención en sí misma.
Conclusión Esta intervención SBL resultó viable y fue bien acogida. Aunque no se observaron mejoras significativas en el rendimiento, el estudio destaca variables contextuales importantes —la duración de la interrupción y la experiencia clínica— que pueden determinar el impacto de la formación futura. Estos resultados respaldan la mejora y la puesta a prueba a mayor escala de la formación estructurada en gestión de interrupciones para el personal de enfermería de triaje.
Descriptores:
Triaje; Seguridad del paciente; Lista de verificación; Estudios de factibilidade; Enfermería de urgência; Servicio de urgencia en hospital
Introduction
Every year over 155 million people seek emergency care in the United States.(1) Upon arrival at the emergency department (ED), patients undergo a triage assessment, which is the critical first interaction between a patient and an emergency healthcare provider. A triage assessment is the critical beginning of the treatment cascade which requires the nurse to conduct an efficient and accurate patient assessment to determine if the patient’s condition is emergent, urgent, or non-urgent. Triage process requires allocation of significant cognitive resources and focused attention from nurses, thus should be conducted in an interruption-free environment.(2,3) However, interruptions are common in the dynamic, unpredictable environment of the ED.(4,5) Triage interruptions can lead to errors such as missed symptom identification, incomplete assessment, or unasked questions and may delay care, resulting in increased patient morbidity or mortality, workload, delays, and errors.(6)
Interruptions have been studied in the ED for decades and the negative effects of interruptions in the ED are well documented.(7,8) Emergency physicians, stretcher-side nurses and triage nurses have been shown to be interrupted at a rate of 6.6 to 7 times an hour.(2,9) Studies have shown that when interrupted, providers failed to return to the original task between 13%(10) and 20% of the time.(8) Although many solutions outside of the ED have been offered to mitigate the impact of interruptions(11-13) such as medication time-out,(11,12) safe zones,(9) and awareness displays,(13) these interventions may not be practical in fast-paced ED triage settings.
It is recommended that nurses learn to manage interruptions in ways that can decrease risks to patient safety.(7,14) Unfortunately, there is currently no training or education specifically available for triage nurses to learn how to avoid interruptions or mitigate the impact of necessary interruptions (e.g. active stroke or myocardial infarct presenting to the ED). Therefore, nurses are required to learn triage interruption management on site or alternatively, not learn it at all.
This ‘on-the-job’ learning style of interruption management can be especially problematic for novice triage nurses who have not yet gained the confidence that comes from experience. Because triage requires nurses to have quick yet efficient assessment skills, insecurity in decision-making due to a lack of confidence can cause critical delays in patient care. Current recommendations by the Emergency Nurses Association state that triage should be conducted by a registered nurse who has completed a standardized triage education course, cardiopulmonary resuscitation, trauma, pediatric, and geriatric education.(15) However, none of these courses address how to manage interruptions. Until the nurse has gained real-world triage experience, intentionally designed learning experiences can provide the triage nurse a safe place to learn to manage the potential dangers of interruptions.
Simulation-based learning (SBL) offers a promising approach to address this training gap providing a controlled, safe environment and has been shown to be an effective method to promote learning among nurses.(16,17) One study identified significant potential for this approach in developing nurses’ abilities to handle workplace distractions.(18) But despite the promise shown by SBL education, this effective method to address interruption management has been seldom used.(17) Few studies have investigated a specific interruption management strategy using SBL,(18,19) but none focus on the emergency setting, let alone triage.
To address this gap, the objective of this research study was to develop and evaluate a SBL intervention specifically designed to prepare triage nurses for effective interruption management. The study’s aims were to evaluate the feasibility of this training and determine if it impacts the proficiency of nurses’ triage interview.
Methods
A quasi-experimental design was used to evaluate the educational intervention for this research. This design was selected over a randomized controlled trial for several pragmatic reasons aligned with implementation science principles.(20) As this pilot study primarily focused on feasibility outcomes, quasi-experimental designs are particularly well-suited when evaluating complex educational interventions in dynamic clinical environments.(21,22) Comparisons were made between the experimental group, where education was provided, and the control group, who did not receive education. Approval was obtained from the University’s Institutional Review Board.
Participants were recruited from a large level 1 Trauma center in the Midwestern region of the United States that employs over 100 nurses in the ED and has over 71,000 patient visits per year. Any emergency nurse currently employed at the facility with one year of ED experience and trained to conduct triage was eligible to participate in this study.
To determine participant numbers needed for detecting a medium effect size G*Power 3.1 was employed. The study needed 40 participants with 20 in each group to achieve a medium effect size (Cohen’s d = 0.5) in triage proficiency assessment at α = 0.05 with 0.80 power. The chosen participant number allowed to detect variations in secondary results and maintained sufficient power for the study because it was anticipated a 15% participant dropout rate.(23-26)The research included 34 nurses who completed the study, with 14 participants in the intervention group and 20 participants in the control group. Unfortunately, the increased demand on the emergency nurses during the COVID-19 pandemic limited the opportunity to provide education and continue the project. Therefore, the intervention group had insufficient participant numbers, which decreased statistical power and possibly created problems with group distribution. Different methods were employed to minimize bias from uneven group sizes while maintaining internal study validity.
Sampling was intentional and non-probabilistic. Participants were chosen through continuous enrollment from one emergency department during their scheduled triage training sessions to ensure all participants had equivalent clinical experience. The participants underwent identical evaluation procedures and onboarding protocols. Validated assessment tools were employed for real-world triage performance to prevent both observer and confirmation bias. Regression tree analysis was employed to identify non-linear patterns while adjusting for confounding variables that emerged because of group allocation. The researchers applied methods that align with best practices for reducing selection bias and enhancing causal inference in quasi-experimental studies when randomization becomes unfeasible.*
One case study about a 43-year-old female with new onset shortness of breath undergoing a triage assessment and two simulations were developed based on the results of a Delphi Panel of triage, education, and operational management experts who provided recommendations for eight interruption management strategies and instructional modalities.(27) The strategies included education on the consequences of interruptions, evaluating the urgency of the interruption, and deciding from three options (ignore, delay, or attend) on the best action to take to manage the interruption. The training was designed to be completed in one session lasting under two hours.
To enhance simulation realism and standardize the evaluation of simulation fidelity, we incorporated the validated Simulation Design Scale (SDS) developed by the National League for Nursing (NLN).(28)The SDS evaluates five key dimensions of simulation design: objectives/information, support, problem-solving, feedback, and fidelity. This tool has demonstrated strong psychometric properties with Cronbach’s alpha values ranging from 0.80 to 0.96 across subscales in multiple validation studies.(29)
Simulations - at a large health system (consisting of a 62 bed Level 1 trauma center with a 12 bed Clinical Decision Unit employing 106 nurses) in the Midwestern United States, two simulation experiences were developed to address six strategies identified by the Delphi Panel.(27) All scenarios were presented to four emergency nurses not enrolled in the study for validation before use in the study.
Study participants played the role of a triage nurse during individual simulated scenarios. Two actors, one playing a triaged patient and one the interrupter, were used in each simulated scenario. The interrupter was trained to cause an interruption during a specific triage component. The actors were given scripts with key elements to include during each interaction, including pertinent history of illness. The actor playing the interrupter was given instructions on when to interrupt the triage nurse and to attempt to keep the interruption length to around 15 seconds. Scenario 1 had the scripted interruption of asking for a wheelchair as the triage nurse was obtaining the patient’s history.
After participating in the simulated case, assessing the patient, and providing an acuity level, participants were debriefed as a group. Each participant then experienced a second individual simulated experience of being interrupted by an aggressive family member asking for a status update as the triage nurse started collecting vital signs. A group debrief followed the second simulation. At the end of each simulation, the principal investigator individually discussed with the study participant strategies that they used or could have used to manage the interruptions. At the end of each session, the participants provided an evaluation of their experience. They provided ratings on several aspects of the training on a scale from 1 (strongly disagree) to 5 (strongly agree).
Two weeks after receiving their training, participants from both groups were observed in actual triage environments. Blinded trained members of the research team, with triage experience, evaluated the nurses’ proficiency in triage interviews and interruption management. The duration of triage and any interruptions that occurred were measured using a validated tool.(30) Each observer scored each nurse on proficiency of a completed triage interview on a scale from 0 to 100.
The research team established interrater reliability (percent agreement was 0.85) by observing 20 triage interviews and assigning a proficiency score using a visual analog scale based on how well the nurses managed and controlled the triage interview. After the first 5 observations, the team met to discuss their results and resolve any scoring discrepancies through consensus.
The outcome variable was the nurse proficiency score assigned during the observations. The independent variables were: Total years of nursing experience; Years of ED experience; Gender; Highest degree obtained; Certifications held; Shift length; Work hours per week; Intervention (education vs. no education); Triage duration; and Interruption duration. Traditional multiple regression analysis was initially used to investigate the potential impact of participants’ characteristics on proficiency.
To complement traditional regression methods and better address the complex, non-linear relationships often present in clinical education datasets, we employed regression tree analysis, to investigate patterns and variations in the outcome variable. The regression tree is a machine learning methodology used to build prediction models.(31,32) The goal is to reduce the variance of the outcome variable by looking at the entire dataset, splitting it into subgroups, and recursively partitioning it into increasingly homogeneous subgroups based on the predictor variables.(32) Using the r-part package in R version 4.2.2, predictor variables were divided into subgroups that decrease the dispersion of the outcome variable to explain decisions and see all possible outcomes. Specifically, the regression tree clusters the data into non-overlapping groups. To prevent overfitting, we employed cost-complexity pruning with 10-fold cross-validation to determine the optimal tree size that minimized prediction error.(33)This approach allowed us to identify meaningful patterns in triage proficiency while maintaining model parsimony and generalizability.
Results
Thirty-four triage nurses participated in this study. All participants received 24 hours of standard triage training. Fourteen nurses were provided with training on how to manage triage interruptions. All data was reported to funding agency per guidelines.(34)
Demographics: Most nurses were female 85.3% (N=29), while the male nurses were 14.7% (N=5). Most nurses were non-Hispanic white 91.2% (N=31), while 5.9% were black (N=2), and 2.9% were Hispanic (N=1). Most nurses had a BSN degree (N=26; 76.5%), while 20.6% had an associate degree (N=7), and 2.9% had an MSN degree (N=1). Over half of the nurses had no certifications (N=20; 58.8%), 26.5% were Certified Emergency Nurses (N=9), while 14.7% had other certifications (N=5). Almost six percent of the nurses reported working less than eight hours per week (N=2), and one reported they worked from 9-23 hours per week. The majority of the nurses (73.5%) reported working from 24-39 hours per week (N=25) while 11.8% of the nurses reported working 40-49 hours per week (N=4) and 5.9% reported a 50–59-hour workweek (N=2). Table 1 for additional demographics.
Evaluation of the intervention: Overall, participants felt the fidelity and realism of the scenarios were strong (M=8.14, SD=1.703). Areas for improvement regarded providing more information at the beginning (M=2.7, SD=1.069). and during the simulation (M=3.21, SD=0.975) on a 5-point scale, both items were rated at the same level of importance by the participants (M = 4.43, SD = 0.646). Table 2 for complete evaluation.
Triage Proficiency: The results showed no significant difference in proficiency scores between the experimental and control groups (p=0.1458). To meet the assumptions for regression analysis, logarithms were taken on proficiency before conducting the two-sample Wilcoxon test due to its non-normal distribution (Shapiro-Wilk normality test: P= 1.459e-05). None of the characteristic variables (years of total experience, years of ED experience, gender, highest degree, shift length, hours worked per week) in either group had a significant impact (F(11,22)=0.3599, p=0.1458, R2 =0.1525).
A regression tree was developed to find the subgroup of the data with a substantial reduction in the variance of the log for proficiency. As shown in figure 1, three subgroups were identified.
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Subgroup 1: all nurses (n=7) who were interrupted for at least 15 seconds and who had total experience less than 4.8 years. Their average proficiency score was 81.45 and variance 0.022.
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Subgroup 2: All nurses (n=15) who were interrupted at least 15 seconds and who had total experience more than 4.8 years. Their average proficiency score was 90.02 with variance 0.0059.
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Subgroup 3: All nurses (n=12) who were interrupted for less than 15 seconds regardless of experience. Their average proficiency score was 99.48 with variance equal to 0.0034.
Discussion
The education was well received by the emergency nurses who participated in the simulations. The use of simulation education programs has been shown to be successful in helping students develop critical thinking in acute care situations(29) but few have been created specifically for practicing nurses already working in the ED environment. A recent integrative review found that simulation-based education is beneficial in increasing risk awareness,(17) which is exactly what emergency nurses need when faced with interruptions. Recognizing that an interruption is occurring and having the critical thinking ability to identify how this could put a patient at increased risk is a key component of this training. The simulations in this study were conducted in the ED during a normal work day which was important to increase the realism of the scenarios.
Overall, triage proficiency was high among all participants. Our findings identified three subgroups. In one subgroup, we observed that triage proficiency remained close to perfect if the nurse was interrupted for less than 15 seconds, regardless if the nurse underwent interruption management training or not. This indicates that short interruptions did not affect performance. Also of note is that nurses having longer interruptions (greater than 15 seconds) but with more experience managed the job reasonably well with proficiency scores close to 90% (Second identified subgroup). On the other hand, nurses having longer interruptions but with less experience did not do as well on the job with their proficiency score close to 80%. Other characteristics of the nurses did not have any influence on the final proficiency score as per the tree. Further research is needed to determine whether the duration of the interruption is the most important variable in evaluating the impact of interruptions on patient care.(6)
It was concluded that a simulation-based learning intervention for triage nurses was feasible and acceptable, but it did not improve interruption management or triage proficiency in comparison to the non-simulation group. Regression tree analysis showed interruption duration and number of years experience rather than a single session of training are the salient factors predictive of performance, consistent with previous literature indicating that interruptions > 15 seconds long will tend to have particularly troublesome effects on performance with less experienced staff. This foreshadows the previously recommended strong need for use of further educative endeavors, as well as system level initiatives addressing clinical interruption management situations.
Although the educational intervention had no statistically significant impact on the proficiency of triage or triage management, it is feasible to administer, especially in combination with traditional triage orientation. Perhaps a two-fold approach would be a more impactful intervention. The participants felt that the education was realistic but needed more guidance at the beginning of the simulation. Therefore, the research team is modifying education to be formatted into a virtual asynchronous format to accommodate shiftwork better and provide nurses with flexibility to complete the education. Additionally, we will be testing the education in conjunction with other interruption management techniques to determine if that impacts the outcomes.
Nevertheless, the study’s importance extends beyond these initial findings. Early-stage intervention studies often require multiple iterations before achieving statistically significant outcomes. This study represents a crucial first step in developing targeted interruption management education for triage nurses—a previously unexplored but critically important area given the frequency and consequences of triage interruptions documented in prior research.(3)
This study had some limitations to consider. First, our sample size was smaller than determined by our a priori power analysis, potentially limiting our ability to detect statistically significant differences between groups, as the last six participants were not able to receive our training. Although we met our goal of obtaining observations from 20 control group participants, only 14 intervention group participants completed the interruption management training. The single-site design also restricts generalizability to other ED settings with different organizational cultures and interruption patterns.(35) Additionally, our reliance on observational assessment of proficiency, may have introduced Hawthorne effects that influenced nursing performance during evaluation periods.(36) The brief nature of the intervention (a single session under two hours) may have been insufficient to produce measurable changes in complex cognitive skills which typically require extended practice for mastery. Finally, the heterogeneity in participants’ prior triage experience and exposure to interruptions may have introduced additional variability in outcomes that our analysis was unable to fully account for.
Conclusion
The use of educational interventions is vital in providing a pragmatic approach to reducing the impact of triage interruptions. The study has shown the feasibility of using the study-described simulation experiences to teach strategies to manage interruptions. Nursing administration and the ED educators were enthusiastic about the education. Because this study was not powered to capture differences between groups, we plan to test this education on a larger scale at other facilities and throughout the hospital system. Keeping interruptions short (less than 15 seconds in duration) might be a key to mitigating the negative impact of interruptions. Additionally, by alerting nurses to disruptive interruptions, there is potential to improve the nurse’s ability to adapt to them and allow them to successfully return to their primary task through the effective application of interruption management strategies.
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