Research| Volume 41, ISSUE 6, P496-502, November 2015

ED Triage Decision-Making With Mental Health Presentations: A “Think Aloud” Study


      Triage is the process whereby persons presenting to the emergency department are quickly assessed by a nurse and their need for care and service is prioritized. Research examining the care of persons presenting to emergency departments with psychiatric and mental health problems has shown that triage has often been cited as the most problematic aspect of the encounter. Three questions guided this investigation: Where do the decisions that triage nurses make fall on the intuitive versus analytic dimensions of decision making for mental health presentations in the emergency department, and does this differ according to comfort or familiarity with the type of mental health/illness presentation? How do “decision aids” (ie, structured triage scales) help in the decision-making process? To what extent do other factors, such as attitudes, influence triage nurses’ decision making?


      Eleven triage nurses participating in this study were asked to talk out loud about the reasoning process they would engage in while triaging patients in 5 scenarios based on mental health presentations to the emergency department.


      Themes emerging from the data were tweaking the results (including the use of intuition and early judgments) to arrive at the desired triage score; consideration of the current ED environment; managing uncertainty and risk (including the consideration of physical reasons for presentation); and confidence in communicating with patients in distress and managing their own emotive reactions to the scenario.


      Findings support the preference for using the intuitive mode of decision making with only tacit reliance on the decision aid.

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        • Kirby MJ
        • Keon WJ
        Mental health, mental illness, and addiction: overview of policies and programs in Canada.
        in: Interim report of the Standing Senate Committee on Social Affairs, Science, and Technology; November 2004; Ottawa, Canada. 2004
        • Clarke D
        • Hughes L
        • Brown AM
        • Motluk L
        Psychiatric emergency nurses in the emergency department: the success of the Winnipeg experience.
        J Emerg Nurs. 2005; 31: 351-356
        • Hadfield J
        • Brown D
        • Pembroke L
        • Hayward M
        Analysis of accident and emergency doctors’ responses to treating people who self-harm.
        Qual Health Res. 2009; 60: 755-765
        • Nordt C
        • Rossler W
        Attitudes of mental health professionals towards people with schizophrenia and major depression.
        Schizophr Bull. 2006; 32: 709-714
        • Marynowski-Traczyck D
        • Broadbent M
        What are the experiences of emergency department nurses in caring for clients with a mental illness in the emergency department.
        Austr Emerg Nurs J. 2011; 14: 172-179
        • Brown AM
        • Clarke DE
        Reducing uncertainty in triaging mental health presentations: examining triage decision-making.
        Int Emerg Nurs. 2014; 22: 47-51
        • Clarke D
        • Brown AM
        • Hughes L
        • Motluk L
        Education to improve the triage of mental health patients in general hospital emergency departments.
        Accid Emerg Nurs. 2006; 14: 210-218
        • Clarke D
        • Dusome D
        • Hughes L
        Emergency department from the mental health client’s perspective.
        Int J Ment Health Nurs. 2007; 16: 126-131
        • Bullard MJ
        • Unger B
        • Spence J
        • Grafstein E
        Revisions to the Canadian Triage and Acuity Scale adult guidelines.
        CJEM. 2008; 10: 136-142
      1. Brown AM, Clarke DE, Spence J. Mental health triage using CTAS: accuracy and interrater reliability. Open Access Emerg Med. in press.

        • Usher K
        • Baker JA
        • Holmes C
        Understanding clinical decision making for PRN medication in mental health inpatient facilities.
        J Psychiatr Ment Health Nurs. 2010; 17: 558-564
        • Muir N
        Clinical decision-making: theory and practice.
        Nurs Stand. 2004; 18: 47-54
        • Hammond KR
        Human Judgment and Social Policy: Irreducible Uncertainty, Inevitable Error, Unavoidable Injustice.
        Oxford University Press, New York, NY1996
        • Nugus P
        • Forero R
        • McCarthy S
        • et al.
        The emergency department carousel: an ethnographically-driven model of the dynamics of patient flow.
        Int Emerg Nurs. 2014; 22: 3-9
        • Crosskerry P
        The cognitive imperative: thinking about how we think.
        Acad Emerg Med. 2000; 7: 1223-1231
        • Offredy M
        • Meerabeau E
        The use of ‘think aloud’ technique, information processing theory and schema theory to explain decision-making processes of general practitioners and nurse practitioners using patient scenarios.
        Prim Health Care Res Dev. 2007; 56: 46-59
        • Van Someren MW
        • Barnard YF
        • Sandberg JAC
        The Think Aloud Method: A Practical Guide to Modelling Cognitive Processes.
        Academic Press, London, England1994
        • Pope C
        • Mays N
        Qualitative Research in Health Care.
        BMJ Books, London, England2000
        • Lincoln Y
        • Guba E
        Naturalistic Inquiry.
        Sage Publications, Newbury Park, CA1985
        • Crosskerry P
        From mindless to mindful practice—cognitive bias and clinical decision-making.
        N Engl J Med. 2013; 368: 2445-2448


      Diana E. Clarke is Associate Professor and Associate Dean (Research), College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.


      Krystal Boyce-Gaudreau is Instructor, Red River College, Winnipeg, Manitoba, Canada.


      Ana Sanderson is Senior Practitioner, Salford Mental Health Liaison Team, Greater Manchester West NHS Foundation Trust, Manchester, United Kingdom.


      John A. Baker is Professor of Mental Health Nursing, School of Healthcare, University of Leeds, Leeds, United Kingdom.