International Journal of Africa Nursing Sciences 18 (2023) 100516 Contents lists available at ScienceDirect International Journal of Africa Nursing Sciences journal homepage: www.elsevier.com/locate/ijans Practice of paediatric triage among nurses in human-resource constrained setting: A cross-sectional study in the Tamale metropolis of Ghana Joyce B.P. Pwavra a,*, Ernestina Safoa Donkor c, Mary Ani-Amponsah a, Kennedy Dodam Konlan b a Department of Maternal and Child Health, School of Nursing and Midwifery, University of Ghana, Accra, Ghana b Department of Adult Health, School of Nursing and Midwifery, University of Ghana, Accra, Ghana c School of Nursing and Midwifery, University of Allied Health Sciences, Ho, Ghana A R T I C L E I N F O A B S T R A C T Keywords: Background: Globally, about 30 million children are said to be in need of emergency health care. Proper emer- Child emergency gency care can help meet the Sustainable Development Goal targets (SDGs) in relation to maternal and child Resource-constrained settings mortality. Triaging in emergency settings is an established effective way of reducing child mortality in health Triage care institutions. Nurses Health Aims: We determined the practice of paediatric triage among nurses working in health facilities in Tamale. Ghana Methods: A cross-sectional design, was used to randomly recruit 173 nurses for the study. Using a pre-tested structured questionnaire, we collected socio-demographic information and the practice of paediatric triage among the respondents. The data was analyzed with Stata version 15.0. Results: The majority of nurses in this study were males (56.07 %). Most of the respondents had a certificate in nursing qualifications. The practice of Paediatric Triage was 78.03 % among the respondents. Paediatric triage was practiced more in the Teaching Hospital (84.52 %) as compared to 64.29 % in the District Hospitals. The practice of paediatric triage was associated with the religion of the respondents (59.12, <0.001) and the hospital of work (29.30, <0.001). The respondents identified inadequate personnel, inadequate logistics, poor under- standing of triage, complexity of triage and tiresome nature as barriers to triage. Conclusion: The desire to practice paediatric triage among nurses in resource constrained settings is high even though inadequate personnel and logistics among others pose as barriers to the successful practice of paediatric triage. 1. Introduction children. To properly triage the patient, the nurse needs to work within 10–15 min of child’s arrival to the hospital. While waiting in a crowded Triage is an essential measure to systematically sort patients so those emergency room, patients should inform the nursing staff if their con- who are most acutely ill or injured receive timely care before their dition has changed. Many of the deaths could be avoided if very sick condition worsens (Duko et al., 2019a; Molyneux & Goka, 2017; Phu- children are identified quickly upon their arrival in the health facility, kubye, Mbombi, & Mothiba, 2019; Sutriningsih, Wahyuni, & Haksama, and treatment is started immediately (Ebrahimi et al., 2016; Elmashad, 2020; Tam, Chung, & Lou, 2018). Within 24 h of admission, Children Mohamed, Gouda, & Fadel, 2020; Ruano et al., 2016). Despite several admitted to the hospital often die because of late identification of interventions to expand the scale of health services for children during severity of illness. (Ebrahimi et al., 2016; Molyneux & Goka, 2017; Reisi, emergencies, inadequate human resources and skills within the health Saberipour, Adienh, Hemmatipour, & Abdolahi Shahvali, 2018). Nurses system (Ali, Taverner, Ghani, Kussor, & Naz, 2013; Craig et al., 2016; must be able to spot severely ill children in congested emergency rooms Gardner & Cowden, 2011; Gruba, Jonathon Gruba, Medcalf, Cieslak, & and move them to the front. Nurses must be able to predict the priori- Smith, 2016) together with under reporting of child deaths and inade- tization/categorization and status of available treatment areas for these quate national data to provide complete and reliable information on Abbreviations: PT, Paediatric triage. * Corresponding author at: Department of Maternal and Child Health, School of Nursing and Midwifery, University of Ghana, Legon, Accra, Ghana. E-mail addresses: jbppwavra@ug.edu.gh (J.B.P. Pwavra), esdonkor@ug.edu.gh (E.S. Donkor), amponsah@ug.edu.gh (M. Ani-Amponsah). https://doi.org/10.1016/j.ijans.2022.100516 Received 6 June 2021; Received in revised form 3 November 2022; Accepted 12 December 2022 Available online 16 December 2022 2214-1391/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by- nc-nd/4.0/). J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 child health, they contribute greatly to the inappropriate policy making total staff strength of 109 out of that number 93 are nurses with 40 of concerning children in Ghana (Kerie, Tilahun, & Mandesh, 2018; Man- them working at the outpatient/emergency units, with a bed capacity of oharan et al., 2018; Reisi et al., 2018). 107. The third hospital, which is Tamale Central Hospital, is to the east There is relatively very little research in the area of Paediatric tri- of Tamale Main Town and located opposite the post office on the Kal- aging (PT) in Ghana. In 2011, the World Health Organization in pohini road and west to the police service and central to the prison’s collaboration with Ministry of Health (MOH), Ghana, in its study of services. It is also known as Old Hospital, formally served as the regional paediatric emergency triaging in some selected district hospitals, found hospital of Northern Region and occasionally served as a referral point interestingly that there was no separate outpatient department for for the upper region until 1974 when it was closed down following the children in any of the health facilities studied and children with emer- commissioning of the current Tamale Teaching Hospital as the Regional gency conditions joined adults in the same queue for their hospital cards Hospital. in all facilities (Who, 2011). Based on the research findings, it was recommended that specific emergency units be established to facilitate 2.3. Sample size determination triaging and prioritise care for children. Despite the fact that most public health facilities within Tamale serve as referral centers for complicated The total paediatric emergency nursing staff in the three hospitals conditions, there seem to be no well-structured triaging system for amounted to 185. A sample size of 162 was arrived at by using Yamane, paediatric units and there are no established protocols requiring triaging 1967 formula for each hospital after which the values were summed up for child cases (Molyneux & Goka, 2017). Some reports suggest that (Yamane, 1967). 10 % of the sample size was added to make up for most children within Tamale die while waiting to receive care at the errors and non-submitted questionnaires, which gave a total sample size hospital (Afaya, Azongo, & Yakong, 2017). Since the literature describes of 177. Thus, a sample size of 177 respondents was required at a desired triaging, an essential component of care as discretionary, the researchers precision of 0.05 and added for 10 % non-response. sought to examine the practice of paediatric triage and socio- demographic factors that influence nurses to do triaging for paediatric 2.4. Selection of participants and data collection emergencies considering that most of the nursing staff at the Emergency Units are not trained as Paediatric Nurses. Data were collected from May to August 2017. We included male and female nurses working at the Paediatric Emergency Units of the three 1.1. Aim hospitals. Nurses working in the emergency departments of the three (3) public hospitals were recruited for the study. One hundred and seventy- We determined the practice of paediatric triage and the socio- seven (177) nurses were selected and sampled using a systematic demographic factors influencing paediatric triaging among nurses random sampling technique. However, all three hospitals were purpo- working in health facilities in Tamale – Ghana. sively selected for the study. Other health care professionals such as medical doctors and lab technicians, in the emergency and outpatient 2. Method units who were not involved in triaging were excluded. Nurses who had been on the emergency units but had worked for less than six months 2.1. Study design were also excluded. Prior to recruitment, a full list of all eligible nurses was obtained In this study, we employed a descriptive cross-sectional design. from the human resources units of the three hospitals. The list was then Nurses working at the Paediatric Units of the Tamale Teaching Hospital numbered, and a sampling interval was determined by dividing the (TTH), Tamale West Hospital, and Tamale Central Hospitals with over sample size over the total population. The respondents were then chosen six months working experience in the Paediatric Emergency Units were using the sampling interval until the last respondent was chosen. The recruited. The philosophical foundation for the study was the positivist chosen respondents were then contacted and given a questionnaire in approach (Abuatiq, 2015; Fuller et al., 2001; Ryan, 2015). In adopting English to fill by the researchers. A modified version of Knabe, Ann’s, the positivist approach to research, which is quantitative, the re- “Applying Ajzen’s Theory of Planned Behavior to a Study of Online searchers embarked on the study of the reality by maintaining a distance Course Adoption in Public Relations Education” (2012), questionnaire between him/her and the researched. This allowed the respondents to was used for this study. The phrase public relation education was give a self-report of how they carry out the triage process in the various replaced by Paediatirc Triage in the modified version of the question- facilities devoured of the ideas of the researcher. In this study, our view naire. The questionnaire was divided into three sections. Section A had was that the socio-demographic and institutional cultural variables questions measuring socio-demographic characteristics of respondents which influence nurses during triaging were objectively measurable. which comprised of 7 items. Section B had questions measuring paedi- atric triage practice with 30 items, while Section C had 10 items 2.2. Setting measuring barriers to the practice of paediatric triage. The questionnaire was piloted by the principal investigator to ensure validity, the was no The study used three (3) hospital outlets in the metropolis, namely, need for further modifications after piloting, as questions were under- the Tamale Teaching hospital, Tamale West hospital and Tamale Central stood and thought of by respondents as appropriately measuring the hospital. These hospitals were used because they had well-structured construct (paediatric triage). Therefore, changes were not made to the paediatric units and served as referral centers for rural and sub- questionnaire. While a Cronbach’s alpha (0.69) was calculated to ensure District Health facilities. The Tamale West and Central hospitals were reliability of the questionnaire. The objective of the study was explained chosen to represent the district hospitals while the Tamale Teaching to the nurses and those who consented to participate were interviewed Hospital represented the tertiary hospital. The Tamale Teaching Hos- using the questionnaire in the form of face-to-face interview after which pital (TTH) was commissioned in 1974 as a Regional Hospital and is now the questionnaires were collected for analysis. Again, permission was fully accredited as a tertiary level healthcare institution to provide the sought from the individual unit heads. Then the selected participants much-needed medical referral center for the Northern sector of the were briefed on the study and after the briefing, they were asked country and provides comprehensive health services to the people of whether they would like to participate in the study and those who had Tamale and its environs. The second hospital was the Tamale West agreed to do so were further briefed on how to complete the question- Hospital, which is to the west of Tamale main town adjacent Picorna naire. The questionnaires were administered to the participants by the Hotel in an area called Zogbeli. It was established in April 1st 1998 as a researchers themselves and it took about 20 – 25 min for each partici- polyclinic and up graded to a district hospital the same year. It has a pant to complete. The completed questionnaires were collected 2 J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 immediately after filling them. The pre-tested structured questionnaire Table 1 collected socio-demographic information and the practice of paediatric Socio-demographic characteristics of respondents. triage among the respondents. The data was entered into Microsoft Excel Variable Frequency Percentage (%) 2010 and imported into the Stata version 15.0 for analysis. Sex Male 97 56.07 2.5. Data analysis Female 76 43.93 We analyzed the data using the Stata version 15. During the analysis, Highest education we did a facility/hospital comparison of socio-demographic variables Certificate 78 45.09 using Pearson’s chi-square (χ2) test, particularly for the dichotomous Diploma 52 30.06 variables. In determining the association of socio-demographic and Degree 42 24.28 Postgraduate 1 0.58 practice of paediatric triaging, we used the Pearson’s χ2. In this study, p < 0.05 was considered statistically significant. Religion Christian 80 46.24 2.6. Ethical considerations Islam 78 45.09 Traditionalist 15 8.67 Ethical approval was sought from the Noguchi Memorial Institute for Medical Research (IRB CPN 015/16-17). The objective of the study was Income level explained to the nurses and those who consented to participate were Low 79 45.66 further briefed on how to complete the questionnaire. The question- Middle 52 30.06 naires were administered to the participants by the first author and it High 42 24.24 took about 30–45 min for each participant to complete the question- naire. The completed questionnaires were collected immediately after Marital status filling them. A total of 177 out-patient/emergency nurses were selected Single 69 39.88 Married 87 50.29 for the study. Of these, 173 questionnaires were successfully completed Separated 17 9.03 representing a response rate of 97.7 %. However, 4 of the questionnaires were incomplete and thus were not used. We obtained permission from Hospital of work the Deputy Director of Nursing Service of the three hospitals prior to District hospital 56 32.37 data collection. Moreover, we explained the purpose of the study to each Teaching hospital 117 67.63 respondent before obtaining written informed consent for the study. Furthermore, we ensured the confidentiality of the data collected by Working experience assigning unique codes to each response. We also maintained privacy 1–3 129 74.57 and ensured anonymity throughout the data collection and analysis of 4–6 18 10.40 7–10 17 9.83 the data. 11–16 9 5.20 3. Results Field data, 2017. A total of one hundred seventy-three (173) respondents took part in Christians. Respondents from the teaching hospitals were predomi- the study. As depicted in Table 1, Majority of the respondents (56.07 %) nantly single compared to their counterparts from the district hospitals were males with only 43.93 % being females. The mean age of the re- who were married. The details are captured in Table 2. spondents was 29.02 ± 3.64. Majority of the respondents (45.09 %) were enrolled nurses and only 24.28 % had a bachelor’s education 3.2. Practice of paediatric triage background. The dominant religions among the respondents were Christianity (46.24 %) and Islam (45.09 %). Further, the study found The results show that the practice of paediatric triage was 78 % that 45.66 % of the respondents reported as having low-income levels as among the respondents. However, nurses from the teaching hospital compared to 24.24 % who reported as having high income level. The indicated a higher level of practice of paediatric triage (84.62 %) as results showed that 50.29 % were married with 39.88 % and 9.03 % compared to 64.29 % from the district hospitals. This is presented in reporting to be single or separated, respectively. Majority of the re- Fig. 1. spondents (67.63 %) worked at the teaching hospital with only 32.37 % being workers of the two district hospitals in this study. Majority of the 3.3. Association between the practice of paediatric triage and socio- respondents (74.57 %) had 1–3 years working experience as nurses. This demographic factors is presented in Table 1 (Table 1) in appendix. The practice of paediatric triage among the respondents was 78.03 % 3.1. Comparison of socio-demographics between the hospitals/facility with 84.62 % of those in the teaching hospitals practicing it compared to 64.29 % in the district hospitals. The study revealed that the hospital Majority of the respondents (67.63 %) were staff of the Tamale work was associated with the practice of paediatric triage (29.30, p < teaching hospital with 32.37 % being staff of the two district hospitals. 0.001), The results revealed that respondents who were Christians and The nurses in the district hospitals had the majority of them being cer- Muslims in the teaching hospital were more likely to practice paediatric tificate nurses (54.29 %) with only 16.07 % of them being degree triage compared to the beliefs in the traditional African religion. Similar holders (Table 2). Comparatively, the nurses at the teaching hospital findings were identified for the respondents from the district hospitals. were holders of diploma and degree educational qualifications with 1 The details are in Table 3. respondent possessing a post graduate qualification. The results revealed that nurses in teaching hospitals had a higher educational 3.4. Barriers to paediatric triage qualification compared to their counterparts from the district hospitals (p < 0.001). Majority of the respondents from the teaching hospital were On the barriers to paediatric triage, the respondents identified the Muslims as compared to those from the district hospitals who were following factors as inhibitors to triage. The factors were the complex 3 J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 Table 2 nature of triage, lack of logistics, inadequate personnel, poor under- Comparison of socio-demographic factors between the study settings. standing, and tiresome nature of triage. Variable Teaching Hospital N District Hospitals N Chi2, p- (%) 117 (67.63) (%) 56 (32.37) value 3.5. First major barrier to paediatric triage Sex 4.240, 0.120 When the respondents were asked of the first major barrier to pae- Male 60 (51.28) 37 (66.07) Female 57 (48.72) 19 (33.93) diatric triage, 83.24 % of the respondents cited inadequate personnel as a major barrier. 8.09 %, 6.94 %, 1.16 %, and 0.58 % identified poor understanding, logistics, tiresome, and complex to perform as a first Highest 33.56, education 0.001 major barrier to triage. Details are in Table 4. < Certificate 42 (35.90) 36 (64.29) Diploma 41 (35.04) 11 (19.64) Degree 33 (28.21) 9 (16.07) 3.6. Second major barrier to paediatric triage Postgraduate 1 (0.85) 0 (0) When the respondents were asked of the second major barrier to Religion 33.40, <0.001 Table 3 Christian 39 (33.33) 41 (73.21) Comparing the association between practice of paediatric triage and socio- Islam 64 (54.70) 15 (26.79) demographic factors in the respondents. Traditionalist 15 (12.82) 0 (0) Variable Total N, (%) Practice of PT (%) χ2, p-value Income level 32.47, Training on PT 109 (63.00) 83 (76.17) 1.156, 0.764 <0.001 Sex of respondent 0.066, 0.797 Low 43 (36.75) 36 (64.29) Male 97 (56.07) 75 (77.32) Middle 41 (35.04) 11 (19.64) Female 76 (43.93) 60 (78.95) High 33 (28.21) 9 (16.07) Highest Education 6.017, 0.111 Certificate 78 (45.09) 57 (73.08) Diploma 52 (30.06) 43 (82.69) Marital status 38.97, Degree 42 (24.28) 35 (83.33) <0.001 Postgraduate 1 (0.58) 0 (0) Single 62 (52.99) 7 (12.5) Hospital of Practice 29.30, <0.001* Married 40 (34.19) 47 (33.93) Teaching Hosp 117 (67.63) 99 (84.62) Separated 15 (12.82) 2 (3.57) District Hosp 56 (32.37) 36 (64.29) Income level 2.941, 0.230 Working 13.27, Low 79 (45.66) 57 (72.15) experience 0.100 Middle 52 (30.06) 43 (82.69) 1–3 84 (71.79) 45 (80.36) High 42 (24.28) 35 (83.33) 4–6 13 (11.11) 5 (8.93) Marital status 2.500, 0.287 7–10 13 (11.11) 4 (7.14) Single 69 (39.88) 58 (84.06) 11–16 7 (5.98) 2 (3.57) Married 87 (50.29) 64 (73.56) Separated 17 (9.82) 13 (76.47) Field data, 2017. Religion of respondents 59.12, <0.001* Christian 80 (46.24) 56 (70) Islam 78 (45.09) 77 (98.72) Traditional 15 (8.67) 2 Field data, 2017. 90.00% 84.62% 80.00% 70.00% 64.29% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% TEACHING HOSP DISTRICT HOSP Fig. 1. Practice of paediatric triage among the study respondents. Field data, 2017. 4 J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 Table 4 Table 6 First major barrier to paediatric triage. Third major barrier to triage. First Major Barrier to PT Frequency Percentage Second Major Barrier to PT Frequency Percentage Complex to perform 1 0.58 Complex to perform 151 87.28 Logistics 12 6.94 Logistics 4 2.31 No personnel 144 83.24 No personnel 5 2.89 Poor understanding 14 8.09 Poor understanding 6 4.47 Tiresome 2 1.16 Tiresome 7 4.05 Total 173 100 Total 173 100 Field data, 2017. Field data, 2017. paediatric triage, 83.24 % of the respondents cited a poor understanding study was 29 years (SD = 3.637). Moreover, 68.2 % (n = 118) were aged of paediatric triage as a major barrier. 5.78 %, 4.05 %, 3.47 % and 3.47 between 26 and 30 years, suggesting a youthful and energetic group of % identified logistics, no personnel, tiresome, and complex to perform as nurses for paediatric triaging as discovered in previous studies (Afaya a second major barrier to triage. Details are in Table 5. et al., 2017; Duko et al., 2019a; Faheim, Ahmed, Aly, & Hegazy, 2019; Phiri et al., 2020; Phukubye et al., 2019). It is observed that most people 3.7. Third major barrier to paediatric triage in Ghana enter the work force at a very young age. Again, following the shortage of nurses and midwives in Ghana generally due to brain drain When the respondents were asked of the third major barrier to in the quest for greener pastures into western countries and retirement paediatric triage, 87.28 % of the respondents cited the complex to of nurses in Ghana, there has been an extensive proliferation of nursing perform paediatric triage as a major barrier. 4.05 %, 3.47 %, 2.89 % and training schools culminating in a large cohort of young nurses 2.31 % identified tiresome, poor understanding, no personnel, and completing from these schools. Even though these schools were estab- inadequate logistics as a third major barrier to triage, respectively. This lished in an attempt to increase the capacity of nurses in the country, the is presented in Table 6. nursing profession and quality appear to suffer. These phenomena might have accounted for the youthful/ strong response group for paediatric 3.8. Summary of results triaging in this current study. In terms of work qualification major of the respondents (45.09 %) The results as shown above indicate that the majority of nurses were enrolled nurses. This finding is similar to the findings of earlier working in paediatric emergency settings in the Tamale metropolis were researchers (Asamani et al., 2019; Atitsogbui & Tawiah, 2019; Bell et al., males. Most of them had certificates in General Nursing qualifications. 2014). Enrolled nurses in Ghana by default are expected to only gain Nurses in the teaching hospital had higher educational qualifications competence in auxiliary nursing activities. This makes their training compared to their counterparts in the district hospitals. The results shorter and enrollment into the work force earlier as well as quicker. It is indicate that there was a high level of practice of paediatric triage in also cheaper and less burdensome to the government of Ghana finan- both settings even though the practice was higher in the teaching hos- cially when enrolled nurses are employed. These reasons could have pital. The practice of paediatric triage was associated with the religion of contributed to the high number of enrolled nurses in this current study. the respondents and the hospital of work. The respondents further The study further found that nurses in the teaching hospital had identified inadequate personnel, inadequate logistics for triage, poor higher educational qualifications compared to their counterparts in the understanding of triage, as barriers to paediatric triage and had a district hospitals. In Ghana the best trained nurses are mostly employed perception of paediatric triage as complex and tiresome. at the tertiary institution that is mostly in the teaching hospitals while we have the diploma and basic certificate holders mostly in the district 4. Discussion hospitals This finding is in line with the works of earlier researchers (Duko et al., 2019b; Gardner & Cowden, 2011; Kerie et al., 2018; Rah- A total of 173 respondents were involved in the study, this study had mati, Azmoon, Kalantari Meibodi, & Zare, 2013). Teaching hospitals as more male nurse respondents 56.07 % (n the name suggest, predominantly teaches, and models the way for = 97) than female nurse re- spondents 43.93 % (n 76) as discovered in previous studies (Chen others, particularly smaller health facilities such as district hospitals. In = et al., 2019; Dekker-Boersema et al., 2019; Recznik, Simko, Travers, & order to accomplish what they are mandated to do, highly qualified Devido, 2019) in Ghana, there is more male enrollment and sustenance nursing staff such as degree nurses and post graduate nurses are required in schools than female enrollment and sustenance. In addition, males in in these facilities. It is therefore not surprising to see a significant the northern region strive for high/tertiary education than many of the number of respondents in the teaching hospital in this study possessing a females, resulting in more male engagement in formal jobs than in the first degree as the minimum educational qualification. Compared to case of females. These practices probably contributed to the greater Australia and Canada it is the same trend. Degree nurses in these number of male nurse respondents in the study. The mean age in this countries perform better triage as compared to nurses of a low cadre (Brouns et al., 2019). The practice of paediatric triage among the nurses was high at 78.03 Table 5 Second major barrier to paediatric triage. % similar finding was reported by (Phukubye et al., 2019; Rahmati et al., 2013; Soogun, Naidoo, & Naidoo, 2017; Tam et al., 2018). The nurses Second Major Barrier to PT Frequency Percentage properly categorised the sick children into emergency, priority, and Complex to perform 6 3.47 normal cases for care and treatment. This was done in a timely manner Logistics 10 5.78 which reduced complications and death (Toloo, Aitken, Crilly, & Fitz- No personnel 7 4,05 Gerald, 2016). Additionally, 84.62 % of the nurses in the teaching Poor understanding 144 83.24 Tiresome 6 3.47 hospitals practiced paediatric triage more than those in the district hospitals 64.29 % (Abdelwahab, Yang, & Teka, 2017; Faheim et al., Total 173 100 2019; Heidarzadeh, Heidarzadeh, & Azadi, 2020; Phukubye et al., 2019). Nurses were able to spot severely ill patients in congested Field data, 2017. 5 J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 emergency rooms and move them to the front. Nurses were able to the work reported in this paper. predict the prioritization and status of available treatment areas for the children (Brouns et al., 2019). The practice of paediatric triage seems to References be high in the teaching hospital probably due to the calibre (degree holders) of nurses found there. Again, the findings of this current study Abdelwahab, R., Yang, H., & Teka, H. G. (2017). A quality improvement study of the seem to suggest that the hospital worked in was associated with the emergency centre triage in a tertiary teaching hospital in northern Ethiopia. African Journal of Emergency Medicine, 7(4), 160–166. https://doi.org/10.1016/j. practice of paediatric triage (29.30, p < 0.001). It appears that there afjem.2017.05.009 may be more resources in the teaching hospital as are found in the Abuatiq, A. (2015). Concept analysis of technostress in nursing. International Journal of district hospital and could be the reason paediatric triage is practiced Nursing & Clinical Practices, 2, 2–5. Afaya, A., Azongo, T. B., & Yakong, V. N. (2017). Perceptions and knowledge on triage of more in the teaching hospital (Abdelwahab et al., 2017; Duko et al., nurses working in emergency departments of hospitals in the Tamale Metropolis, 2019a; Faheim et al., 2019; Heidarzadeh et al., 2020; Rahmati et al., Ghana. IOSR Journal of Nursing and Health Science, 06(03), 59–65. https://doi.org/ 2013). In Manchester triage is highly performed and has contributed 10.9790/1959-0603065965 Ali, S., Taverner, B. C. B., Ghani, M., Kussor, Z., & Naz, S. (2013). Knowledge of triage immensely to reducing complications among sick children who attend among nurses in emergency units. International Journal of Nursing, 29, 240–243. the emergency department as well as reduce deaths among children in Aloyce, R., Leshabari, S., & Brysiewicz, P. (2014). Assessment of knowledge and skills of that state (Worth, Davis, Wallace, Bartlett, & Travers, 2019). Muslim triage amongst nurses working in the emergency centres in Dares Salaam, Tanzania. African Journal of Emergency Medicine, 4(1), 14–18. https://doi.org/10.1016/j. nurses 77 (98.72 %) were more likely to perform paediatric traige in this afjem.2013.04.009 study. This trend may be from the belief that human beings(children) Asamani, J. A., Amertil, N. P., Ismaila, H., Francis, A. A., Chebere, M. M., & Nabyonga- and their fundamental rights hold an important place in Islam. Human Orem, J. (2019). Nurses and midwives demographic shift in Ghana – The policy implications of a looming crisis. Human Resources for Health, 17(1), 1–5. https://doi. beings are the highest ring of the chain of living creatures in the uni- org/10.1186/s12960-019-0377-1 verse. Humans are the superior and most honourable creatures of Allah. Atitsogbui, J., & Tawiah, K. A. (2019). In Turnover intention and job fit among nurses in The most fundamental right of human beings is the right to live and it is Ghana : Does psychological climate matter ? January 2018 (pp. 546–557). https://doi. superior to anything else. Everything which may violate the right to live org/10.1002/nop2.240 Bell, S. A., Arbor, A., Rominski, S., Reach, G., Arbor, A., Bam, V., … Arbor, A. (2014). is prohibited in Islam. The fact that the right to live is superior to all HHS Public Access, 15(2), 244–249. https://doi.org/10.1111/nhs.12026.An other rights hold a great importance in Islam as well as all other religions Bijani, M., & Khaleghi, A. A. (2019). Challenges and barriers affecting the quality of and legal regulations regarding the preservation of this right (Elcioglu & triage in emergency departments: A qualitative study. Galen Medical Journal, 8. https://doi.org/10.31661/gmj.v8i0.1619 Unluoglu, 2004; O’Leary, Abdalla, Hutchinson, Squire, & Young, 2020; Brouns, S. H. A., Mignot-Evers, L., Derkx, F., Lambooij, S. L., Dieleman, J. P., & Rotabi, Bromfield, Lee, & Sarhan, 2017). Haak, H. R. (2019). Performance of the Manchester triage system in older emergency Nurses in this current study identified lack of resources, poor un- department patients: A retrospective cohort study. BMC Emergency Medicine, 19(1). https://doi.org/10.1186/S12873-018-0217-Y derstanding of triage, lack of personnel, lack of logistics, the complex Chen, W., Linthicum, B., Argon, N. T., Bohrmann, T., Lopiano, K., Mehrotra, A., … nature, and tiresome nature of triage as hindrances to the practice of Ziya, S. (2019). The effects of emergency department crowding on triage and paediatric triage. Though the practice was generally high, it could be hospital admission decisions. American Journal of Emergency Medicine. https://doi. org/10.1016/j.ajem.2019.06.039 better when these barriers are mitigated towards optimal paediatric Craig, L. E., McInnes, E., Taylor, N., Grimley, R., Cadilhac, D. A., Considine, J., & triage (Aloyce, Leshabari, & Brysiewicz, 2014; Bijani & Khaleghi, 2019; Middleton, S. (2016). Identifying the barriers and enablers for a triage, treatment, Craig et al., 2016; Gruba et al., 2016; Hamm, 2008; Molyneux & Goka, and transfer clinical intervention to manage acute stroke patients in the emergency department: A systematic review using the theoretical domains framework (TDF). 2017). The recommendation however is that paediatric triage is very Implementation Science, 11(1). https://doi.org/10.1186/s13012-016-0524-1 important, and that Nurses who perform it among children need to have Dekker-Boersema, J., Hector, J., Jefferys, L. F., Binamo, C., Camilo, D., Muganga, G., … the proper knowledge, skill, behavior toward its performance and the Hobbins, M. A. (2019). Triage conducted by lay-staff and emergency training right resources to perform this all-important task that contributes to reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique. African Journal of Emergency Medicine, 4, 1–5. https://doi. reducing child illness complications and deaths. org/10.1016/j.afjem.2019.05.005 Duko, B., Geja, E., Oltaye, Z., Belayneh, F., Kedir, A., & Gebire, M. (2019a). Triage 5. Limitations of the study knowledge and skills among nurses in emergency units of Specialized Hospital in Hawassa, Ethiopia: Cross sectional study. BMC Research Notes, 12(1), 3–7. https:// doi.org/10.1186/s13104-019-4062-1 The study used a cross-sectional design making it difficult to infer Duko, B., Geja, E., Oltaye, Z., Belayneh, F., Kedir, A., & Gebire, M. (2019b). Triage causation. In addition, since the study depended on a pre-tested ques- knowledge and skills among nurses in emergency units of Specialized Hospital in Hawassa, Ethiopia: Cross sectional study. BMC Research Notes, 12(1), 19–22. https:// tionnaire which largely depended on the respondent’s responses and doi.org/10.1186/s13104-019-4062-1 recall, there is a high possibility of recall bias. Furthermore, income Ebrahimi, M., Mirhaghi, A., Mazlom, R., Heydari, A., Nassehi, A., & Jafari, M. (2016). levels are usually associated with some social status in society, hence The role descriptions of triage nurse in emergency department: A Delphi study. Scientifica, 2016. https://doi.org/10.1155/2016/5269815 some of the respondents could claim to be in the high social brackets Elcioglu, O., & Unluoglu, I. (2004). Triage in terms of medicine and ethics. Saudi Medical when actually they are not and vis-versa. Journal, 25(12), 1815–1819. Elmashad, H. A. M., Mohamed, A., Gouda, I., & Fadel, E. A. (2020). Effect of implementing simulation obstetric triage training on nurses’ knowledge and Declarations practices. International Journal of Nursing Didactics, 10(02), 27–37. https://doi.org/ 10.15520/ijnd.v10i02.2805 Not Applicable. Faheim, S. S., Ahmed, S. S., Aly, E. F. A. M., & Hegazy, S. M. A. (2019). Effect of triage education on nurses’ performance in diverse emergency effect of triage education on nurses’ performance in diverse emergency departments. Evidence-Based Nursing Consent for publication Research, 1(2), 53–63. https://www.researchgate.net/profile/Safaa_Solima/publica tion/334151931_Effect_of_Triage_Education_on_Nurses’_Performance_in_Diverse Not applicable. _Emergency_Departments/links/5d1a8163a6fdcc2462b72e70/Effect-of-Triage -Education-on-Nurses-Performance-in-Diverse-Emergency. Fuller, S., Sciences, B., Durkheim, E., Turner, J. H., Sciences, B., Sciences, N., & Funding Positivism, L. (2001). Positivism, history of positivism: Sociological positivism. International Encyclopedia of the Social & Behavioral Sciences. Gardner, J., & Cowden, N. (2011). Triage in the emergency department: Role challenges, There was no funding for this study. satisfaction , and perceptions of staff. Gruba, J. J., Jonathon Gruba, B., Medcalf, S. J., Cieslak, T., & Smith, P. W. (2016). Declaration of Competing Interest Barriers to pediatric triage guideline compliance: A survey of Nebraska Emergency Departments. Hamm, J. R. (2008). How to overcome triage barriers. Journal of Emergency Nursing, 34 The authors declare that they have no known competing financial (3), 241–242. https://doi.org/10.1016/j.jen.2008.02.023 interests or personal relationships that could have appeared to influence 6 J.B.P. Pwavra et al. I n t e r n a t i o n a l J o u r n a l o f A f r i c a N u r s i n g S c i e n c e s 18 (2023) 100516 Heidarzadeh, H., Heidarzadeh, Z., & Azadi, A. (2020). Comparison of pre-hospital triage in teaching hospitals. Journal of Nursing and Midwifery Sciences, 5(1), 32. https://doi. training by role playing and lecture on nursing students’ knowledge, attitude and org/10.4103/jnms.jnms_5_18 performance. Nursing Open, 7(4), 935–942. https://doi.org/10.1002/nop2.464 Rotabi, K. S., Bromfield, N. F., Lee, J., & Sarhan, T. A. (2017). The care of orphaned and Kerie, S., Tilahun, A., & Mandesh, A. (2018). Triage skill and associated factors among vulnerable children in Islam: Exploring Kafala with Muslim social work practice with emergency nurses in Addis Ababa, Ethiopia 2017: A cross-sectional study. BMC unaccompanied refugee minors in the United States. Journal of Human Rights and Research Notes, 11(1), 4–9. https://doi.org/10.1186/s13104-018-3769-8 Social Work, 2(1–2), 16–24. https://doi.org/10.1007/s41134-017-0027-2 Manoharan, M., Sc, M., Ravindran, V., Ranjini, K., Jacob, E., Johnson, M. A., … Ruano, P., Delgado, L. L., Picco, S., Villegas, L., Tonelli, F., Merlo, M., … Masuelli, M. Author, C. (2018). Knowledge on triaging among pediatric nurses in pediatric (2016). We are IntechOpen, the world ’ s leading publisher of Open Access books emergency services (PES). IOSR Journal of Nursing and Health Science (IOSR-JNHS), 7 Built by scientists, for scientists TOP 1 %. INTECH, Tourism, 13. https://doi.org/ (1), 1–05. https://doi.org/10.9790/1959-0701050105 10.5772/intechopen.86227 Molyneux, E. M., & Goka, B. Q. (2017). Paediatric emergencies in sub-Saharan Africa. Ryan, P. (2015). Positivism: Paradigm or culture? Policy Studies, 36(4), 417–433. https:// African Journal of Emergency Medicine, 7, S1–S2. https://doi.org/10.1016/j. doi.org/10.1080/01442872.2015.1073246 afjem.2017.11.005 Soogun, S., Naidoo, M., & Naidoo, K. (2017). An evaluation of the use of the South O’Leary, P., Abdalla, M., Hutchinson, A., Squire, J., & Young, A. (2020). Child protection African triage scale in an urban district hospital in Durban, South Africa. South with Muslim communities: Considerations for non-Muslim-based orthodoxies/ African Family Practice, 59(4), 133–137. https://doi.org/10.1080/ paradigms in child welfare and social work. British Journal of Social Work, 50(4), 20786190.2017.1307908 1201–1218. https://doi.org/10.1093/bjsw/bcz088 Sutriningsih, A., Wahyuni, C. U., & Haksama, S. (2020). Factors affecting emergency Phiri, M., Heyns, T., & Coetzee, I. (2020). Patients’ experiences of triage in an emergency nurses’ perceptions of the triage systems. Journal of Public Health Research, 9(2), department: A phenomenographic study. Applied Nursing Research, 54(October 85–87. https://doi.org/10.4081/jphr.2020.1808 2019), Article 151271. https://doi.org/10.1016/j.apnr.2020.151271 Tam, H. L., Chung, S. F., & Lou, C. K. (2018). A review of triage accuracy and future Phukubye, T. A., Mbombi, M. O., & Mothiba, T. M. (2019). Knowledge and practices of direction 11 medical and health sciences 1117 public health and health services. triage amongst nurses working in the emergency departments of rural hospitals in BMC Emergency Medicine, 18(1), 1–7. https://doi.org/10.1186/s12873-018-0215-0 Limpopo Province. The Open Public Health Journal, 12(1), 439–448. https://doi.org/ Toloo, G. S., Aitken, P., Crilly, J., & FitzGerald, G. (2016). Agreement between triage 10.2174/1874944501912010439 category and patient’s perception of priority in emergency departments. Rahmati, H., Azmoon, M., Kalantari Meibodi, M., & Zare, N. (2013). Effects of triage Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 24(1). https:// education on knowledge, practice and qualitative index of emergency room staff: A doi.org/10.1186/S13049-016-0316-2 quasi-interventional study. Bulletin of Emergency and Trauma, 1(2), 69–75. http Who. (2011). In Assessment of quality of care for children in selected hospitals in Ghana (pp. ://www.ncbi.nlm.nih.gov/pubmed/27162827%0Ahttp://www.pubmedcentral.nih. 1–140). gov/articlerender.fcgi?artid=PMC4771226. Worth, M., Davis, L. L., Wallace, D. C., Bartlett, R., & Travers, D. (2019). Are Emergency Recznik, C. T., Simko, L. C., Travers, D., & Devido, J. (2019). Pediatric triage education Departments in the United States following recommendations by the emergency for the general emergency nurse: A randomized crossover trial comparing simulation severity index to promote quality triage and reliability? Journal of Emergency Nursing, with paper-case studies. Journal of Emergency Nursing, 45(4), 394–402. https://doi. 45(6), 677–684. https://doi.org/10.1016/j.jen.2019.05.006 org/10.1016/j.jen.2019.01.009 Yamane, Y. (1967). Mathematical formulae for sample size determination. Scientific Reisi, Z., Saberipour, B., Adienh, M., Hemmatipour, A., & Abdolahi Shahvali, E. (2018). Research Publishing. The level of awareness of the emergency department nurses of the triage principles 7