KIBOGORA POLYTECHNIC 
                     FACULTY OF HEALTH SCIENCE
                  DEPARTMENT OF GENERAL NURSING A0 
TOPIC: ASSESSMENT OF FACTORS AFFECTING NURSES AND MIDWIVES TRIAGE DECISIONS MAKING AND TRIAGE ACCURACY IN EMERGENCY DEPARTMENT OF KIBOGORA DISTRICT HOSPITAL

A Research Paper submitted in partial fulfillment of the requirements for the Bachelor’s degree with honor in General Nursing

PREPARED BY:                                                                                                                                                                
MUKAMUGISHA Dieu Merci Chartine
1900392

NDAGIJIMANA Jean Pierre
1900435

SUPERVISOR: MUVANDIMWE Jean de la Croix (Assistant Lecturer)  

                                                 Kibogora, August 2022
DECLARATION
Declaration by the Candidates
We MUKAMUGISHA Dieu Merci Chartine and NDAGIJIMNANA Jean Pierre hereby declare that this our own original works and not a duplication of any similar academic work. It has therefore not been submitted to any other institution of higher learning. All materials cited in this paper which are not our own have been duly acknowledged.

MUKAMUGISHA Dieu Merci Chartine 		Signature…………………..
NDAGIJIMANA Jean Pierre			Signature…………………..         
Date : 9th September 2022

Declaration by the Supervisor
I declare that this work has been submitted for examination with my approval as KP Supervisor
SUPERVISOR’S NAME: …………………..
SIGNED………………..
DATE………………

ABSTRACT
Background: Triage is the process of determining the priority of patients' treatments based on the severity of their conditions. Accurate triaging of patients in emergency departments is crucial, since triage determines how quickly patients are prioritized   appropriately, cared for in a timely manner. Correct decision-making of triage is the basis of prioritization as it has an important effect on patients’ outcomes. The aim of this study was to assess factors affecting nurses and midwives triage decision making and triage accuracy in emergency department of Kibogora district hospital. 
Methodology: A quantitative approach and descriptive cross-sectional design were adopted to conduct this study. A non-probability convenience sampling strategy was used to select the nurses and midwives who met the study inclusion criteria to get the sample. A sample size of 34 nurses and midwives was considered in this study. Data were collected using a structured questionnaire and a statistical package for social sciences version 26 was used to analyze them. 
Results: The study was conducted in 34 nurses and midwives who were working in emergency and maternity department of Kibogora district hospital and majority of the participants (94.1%) had accepted that knowledge and skills affect triage decision making and that triage accuracy can be affected by unity overcrowdings/patient overload at 88.2%. A strong positive relationship was found between social demographic factors and triage accuracy where gender, job titles and qualification were having those p values (p=0.014, 0.035, 0.021) respectively. This study showed that level of education, being motivated, impact of availability of medical equipment and availability of Cardiotocography machines, vital signs monitors and electrocardiogram machines (p values= 0.023, 0.029, 0.016, 0.048) respectively, together with gender, job title and qualification were found to be the only factors affecting triage decision making and triage accuracy in Kibogora district hospital. 
Conclusion and recommendation: Findings from  this study demonstrated  that Nurses/midwives of emergency departments of Kibogora district hospital were still facing with many factors that affect their triage decision making and triage accuracy and this results in inaccuracy of triage and it may read to morbidity and mortality due to delay in administration of care to critically ill patients. Therefore Kibogora District hospital needs improvement in resources management specifically at the emergency departments. 
DEDICATION

This dissertation is firstly dedicated to our God the Almighty for his everlasting love and blessings; it is dedicated to our school which gives us an opportunity to upgrade our studies in general nursing; it is dedicated to our beloved families, relatives and friends who have given their precious time and invaluable support in different ways. It is also dedicated to our classmates, who always stood with us in this whole journey, and to everyone who will be interested in exploring the content in here, 
May almighty God bless you abundantly!  

ACKNOWLEDGEMENT

We want to express our deepest sense of gratitude to almighty God for his blessings and for enabling us in every step we made to progress up to this stage. Our particular acknowledgement goes to MUVANDIMWE Jean de la Croix, despite a lot of responsibilities, he accepted to supervise us during this dissertation. We acknowledge his simplicity, cooperation, courage and meticulous guidance that permitted us to go through this research and we are very grateful for that. 
We thank Kibogora hospital administration which allow us to conduct our research in the institution mentioned above. We thank a medical doctor who helped us in research questionnaire preparation; Mr MURINZI Alexandre Edgard, may God bless him and keep the heart of helping. 
We highly acknowledge and convey our deep appreciation to our respective parents and lovely ones whose support can’t be exhausted from the beginning till now. We also want to thank Kibogora polytechnic school which made this program possible. 
We really extend our thanks and appreciation to all lecturers for their shared knowledge and skills which have been a major tool for guidance to achieve this present stage of learning. We express more sincere gratitude to nurses and midwives for their genuine cooperation during our studies and we thank everyone who participates in our research and who will take a time to read this dissertation.

LIST OF TABLES

Table 1 Socio-demographic characteristics of the participants
Table 2 description of factors affecting nurses/midwives triage decision making
Table 3 The correlation between socio - demographic data and factors affecting triage accuracy
Table 4 Correlation between factors affecting nurses/ midwives triage decision making and factors affecting nurse/midwives triage accuracy in kibogora district hospital.

                                                                     

LIST OF FIGURES

Figure 1: Level of triage systems………………………………………………………………..
Figure 2: Conceptual frame work adapted from Ajzen and Fischbein, 1980)………………….

ACRONYMS

BLS: Basic Life Support
BTLS: Basic Trauma Life Support
DH: District Hospital
ECG: Electrocardiogram
EDM: Emergency department management
EDs: Emergency Departments
ETAT: Emergency Triage Assessment and Treatment
HCWs: Health care workers
SPSS: Statistical Package for the Social Sciences
WHO: World Health Organization 

TABLE OF CONTENTS
DECLARATION
ABSTRACT
DEDICATION
ACKNOWLEDGEMENT
LIST OF TABLES
LIST OF FIGURES
ACRONYMS
CHAPTER ONE: GENERAL INTRODUCTION
1.0 INTRODUCTION
1.1 BACKGROUND OF THE STUDY
1.2 PROBLEM STATEMENT
1.3. PURPOSE OF THE STUDY
1.4. RESEARCH QUESTION
1.5. OBJECTIVES OF STUDY
1.6. SIGNIFICANCE OF THE STUDY
1.6.1. Scientific interest
1.6.2. Society interest
1.6.3. Personal interest
1.7. LIMITATIONS OF THE STUDY
1.8. SCOPE OF THE STUDY
CHAPTER TWO: LITERATURE REVIEW
2.0 INTRODUCTION
2.1	. DEFINITION OF KEY TERMS AND CONCEPTS
2.2	LITERATURE REVIEW
2.2.0. Social demographic factors that affect nurses/midwives triage decision making and triage accuracy in emergency and maternity department
2.2.1. Factors affecting nurses/midwives triage decision making and triage accuracy
2.2.2 Factors which affect nurses/midwives triage decision making and triage accuracy
CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGY
3.0 INTRODUCTION
3.1 RESEARCH APPROACH AND STUDY DESIGN
3.2 TARGET POPULATION
3.3. SAMPLING PROCEDURE
3.4 SAMPLE SIZE
3.4.1. Inclusion criteria
3.4.2 Exclusion criteria
3.5 RESEARCH INSTRUMENTS FOR DATA COLLECTION
3.6 DATA COLLECTION PROCEDURES
3.7 ETHICAL CONSIDERATIONS
3.8 DATA ANALYSIS
3.9 RELIABILITY AND VALIDITY MEASURES
CHAPTER FOUR: DATA PRESENTATION, ANALYSIS, INTERPRETATION AND SUMMARY
4.0 INTRODUCTION
4. 1 DATA PRESENTATION AND ANALYSIS
4.1.0. Description of participant’s demographic data
4.1.1. Description of factors affecting nurses/midwives triage decision making
4.2.1. The correlation between socio-demographic data and factors affecting triage accuracy.
4.2.2. The correlation between factors affecting nurses/ midwives triage decision making and factors affecting nurse/midwives triage accuracy in kibogora district hospital.
4.3. DISCUSSION OF FINDINGS
4.3.0. Discussion of social demographic factors which affect triage decision making and triage accuracy
4.3.1. Discussion of Factors affecting nurse/midwives triage decision making and triage accuracy at Kibogora district hospital
4.3.2. Association between Variables
4.4. SUMMARY OF FINDING
CHAPTER FIVE: GENERAL CONCLUSION AND RECOMMENDATIONS
5.0 INTRODUCTION
5.1 CONCLUSIONS
5.2 RECOMMENDATIONS
REFERENCE
Appendices

CHAPTER ONE: GENERAL INTRODUCTION
1.0 INTRODUCTION
The assurance of the best possible care in emergency situations depends on the implementation of a rapid triage system and strapping knowledge of triage among nurses. The aim of this study is to assess factors affecting nurses and midwives triage decision making and triage accuracy in emergency department at Kibogora district hospital. 
This chapter will contain background of the study, problem statement, and purpose of the study, research question, and objective of the study, significance of the study, limitation of the study and scope of the study. (Geary U et al., , 2010)
1.1 BACKGROUND OF THE STUDY
Triage is the process of determining the priority of patients' treatments based on the severity of their conditions (Fathoni M et.al, 2015). This helps treating patients efficiently when resources are insufficient for all to be treated immediately. Health care providers use Emergency Triage Assessment and Treatment (ETAT) guideline during triaging patients to improve quality of care and reduce morbidity and mortality rates. Triage is the point at which emergency care begins (emergency department; triage; triage knowledge; triage skills, 2021). 
The Australian college for emergency medicine [ACEM] state that triage should be performed by a “suitably experienced and trained registered nurse or medical practitioners”. Accurate triaging of patients in emergency departments (EDs) is crucial, since triage determines how quickly patients are assessed and treated. Understanding the factors that influence ED nurses’ triage decisions making is important to ensure that patients are prioritized   appropriately and cared for in a timely manner. (Gorick H et al., 2022). Nurses/midwives triage decisions making are influenced by several factors relating to the patient, the nurse, the triage algorithm and the environment where triage takes place (Profile, S E E, 2022) . Nurses’ ability to triage patients accurately is negatively affected by high patient numbers, inadequate staffing levels, lack of privacy and lack of training (Profile, S E E, 2022). 
Triage is a process used to determine the severity of illness or injury and to prioritize patients according to the needs for medical care, irrespective of their order of influx or other factors including gender, age, and socioeconomic status (Gerber, et, al, 2006).Triage may result in determining the order and priority of emergency transport, the order and priority of emergency treatment, or the transport destination for the patient (Gerber, et, al, 2006)
 Actually, correct decision-making of triage is the basis of prioritization and providing emergency cares has an important effect on patients’ outcomes (Considine J et al., , 2007). It should be considered that nowadays correct decision- making is counted as an important part of nursing cares, but considering the sensitivity and criticality of the patients’ conditions the importance of this decision making in emergency conditions is double (Göransson K et al., , 2006)
Triage decision-making is a complex clinical decision-making because often this decision-making is done in unclear conditions and by having incomplete and ambiguous information and also is done with the limitation of time and place (Göransson K et al., , 2006). Triage nurses are responsible for rapid diagnosis of life threatening situations and doing rapid actions regarding resolving these conditions (Considine J et al.,, 2007).Triage nurses in order to do accurate triage should be able to diagnose useful clues among all the available information and they should be able to have correct triage decision making based on these clues. The aim of an in-hospital triage system is to rapidly identify patients with life-threatening conditions, ensure treatment in order of clinical urgency, and that treatment is appropriate. 
Worldwide, nurses and midwives in order to make correct triage decision and accuracy of triage need to be having a high level of cognitive knowledge and also having skill, expertise, competence, qualification and readiness for triage decision-making (Geary U et al., , 2010)
A study conducted In Taiwan, approximately 24.3% of nurses’ triage ratings were under triaged and 19.7% were over triaged (Shu-shin Chen et al., 2010). And having adequate working experience, awareness of diseases signs and symptoms and adequate equipment and resources played an important role in correct triage decision making (Woolwich C et al., 2018).  In Southern Thailand, A prospective observational design was performed aiming to measure the accuracy of triage, the sample comprised 109 registered nurses and 1,090 adult patients and only 52.4% of patients were categorized into an accurate triage group and working experience in the emergency department was said to increase the likelihood of over-triage (Thassanee S et al.,, 2018)
A similar study conducted in Hawassa/Ethiopia revealed that 48.5% of triage nurses were found with poor knowledge about triage (Duko B et al., 2019). A study conducted in Easter African, especially   in Tanzania had showed that 78% emergency nurses were reported to be working without formal training in emergency nursing (Afaya A et al,, 2017)
A study conducted in Rwanda revealed that nurses working in emergency department of referral hospitals have low level of triage knowledge and skills on emergency triage and that 40.6 % of ED nurses had no triage training (Innocent T et al., , 2021)
1.2 PROBLEM STATEMENT
Congestion and overcrowding of emergency departments (EDs) is a universal and ever-increasing problem worldwide and a triage system have been in place to facilitate the prioritization of patients while providing emergency cares based on their clinical situations.(Edwards et al., 2015).Accurate triaging of patients in emergency departments (EDs) is crucial, since triage determines how quickly patients are assessed and treated (Gorick H et al., , 2022). In emergency departments, every second is important for patients and the duration of time spent in an emergency department can determine the patient's death, disability, or return to life; Understanding the factors that affect EDs nurses& midwives’ triage decisions making and triage accuracy is important to ensure that patients are prioritized appropriately and cared for in a timely manner (Gorick H et al.,, 2022).
Rising number of patients in Emergency departments can lead to overcrowding, which frequently results in poor or negative patients’ outcome and organizational problems (Geary U et al., , 2010)Nurse’s triage decision making is a serious concern for that problem (Afaya A et al., , 2017). In the study of Cone and Murray revealed that having experience and being an expert were reported as the most important factors affecting nurses’ triage decision-making (Cone et al., , 2002).According to WHO, 2006 if a patient is not triaged properly in the first few minutes of entering the hospital and does not receive effective clinical care, Nurses may not be able to provide effective care to that patients.
Despite different studies, no matter how emergency departments of Rwandan referral hospitals are structured; triage is still performed by nurses with limited educational preparation and knowledge to respond to the overcrowded patients in ED (Niwenkunda J et al., , 2015). According to statistics of Rwanda Demographic and Health Survey 2014-15 (2014-15 DHS), a majority of childhood deaths were due to easily treatable time sensitive illnesses; providing timely access health care to those children can contribute to significance reduction of this mortality.

Therefore, this study intended to assess the factors affecting nurses/midwives’ triage decision making and triage accuracy and this will be one of the means which will help health care providers mostly nurses and midwives to promote the effectiveness of triage. 
1.3. PURPOSE OF THE STUDY	
This study aimed to assess factors affecting nurses and midwives triage decision making and triage accuracy in emergency and maternity departments at Kibogora DH
1.4. RESEARCH QUESTION
1. What are social demographic factors that affect nurses and midwives triage decision making and triage accuracy in emergency and maternity services at Kibogora DH?
2. What are the factors affecting triage decision making and triage accuracy in emergency department at Kibogora DH?
1.5. OBJECTIVES OF STUDY
1.	To identify socio demographic factors affecting nurses and midwives’ triage decision making and triage accuracy in emergency and maternity services at Kibogora district hospital
2.	To determine factors affecting triage decision making and triage accuracy in emergency department at Kibogora district hospital
1.6. SIGNIFICANCE OF THE STUDY
1.6.1. Scientific interest
This study will provide data that will act as a reference for the future research papers to be done concerning this area of study. Not only that, but will also provide researchers and students with new knowledge that has been gained from carrying out this study.
1.6.2. Society interest
After the completion of the study, there is awareness of gaps in triage accuracy and in taking decisions regarding triage among nurses and this will help KIBOGORA DH to know what is missing, what to reinforce, what to improve and what to correct so that the hospital emergency triage policy should be putted into actions and thus it will read to positive patient’s outcomes for those who are in need of emergency cares. 
1.6.3. Personal interest
Through doing this study, we will be able to meet academic requirements as set by our university teaching body; we were able to acquire skills in doing research as this was the first experience and we had enjoyed our participation in improvement of nurses/midwives ‘triage decision making and triage accuracy in Kibogora DH.
1.7. LIMITATIONS OF THE STUDY
The study was conducted at Kibogora District Hospital and the results weren’t generalized to other District hospitals in Rwanda because of the small sample size of nurses/midwives working in Eds of Kibogora DH and the findings were not widespread/ generalized to the other health care providers or staff working in the same hospital. The sample size was supposed to be all 37 nurses/midwives working in emergency and maternity but only 34 of them participate in our research other 3 refuses for their personal reasons.     
1.8. SCOPE OF THE STUDY
This study will be conducted in a period of 2 months, and it will be conducted among Nurses, and Midwives who work in emergency and maternity departments at Kibogora DH from 1st May 2022 till 30th June 2022.

CHAPTER TWO: LITERATURE REVIEW

2.0 INTRODUCTION
This chapter was describing the key terms with appropriates definition related to all objectives and any other relevant literature to support this study.
This chapter reviews literature related to knowledge and skills   on triage among nurses and midwives working in emergency   departments of Kibogora district hospital and is divided into special objectives such as factors affecting nurses/ midwives triage decision makings and factors affecting triage accuracy. Simply it comprises introduction to triage, colours used to triage in emergency departments; purpose of triage, types of triages and important skills to have during in emergency situations.
2.1	. DEFINITION OF KEY TERMS AND CONCEPTS
Triage: The definition of triage used in the context of this thesis is management and sorting of patients according to an assessment of medical need, prioritization, and evacuation, by the use of a sorting system or algorithm. In a disaster, triage seeks to provide the greatest benefit to the largest number of casualties in order to minimize morbidity and mortality.
Emergency Department: the term refers to the place where the patients diagnosed with certain diseases and treated before sending to the wards according to severity index.(Prapp.ctical triage,2020).
Triage Decision making: Triage decision making is based on critical thinking, cognitive skills, intuition, and experience (Cone, 2000). A review of the triage decision-making research emphasizes on experience level of the nurse, use of intuition, and various cognitive factors that influence decision making in emergency situations. (Fathoni M et.al, 2015)
Triage accuracy:	Triage accuracy is defined as a correct allocation for patients to receive emergency service in the best suitable time according to the severity of their condition (Fathoni M et.al, 2015)
	
Related Factors: the term refers to any factor or variable that affects the knowledge and ability of nurses to triage in emergency departments. (Yulp. 2019).  
Socio-demographics: are nothing more than characteristics of a population. Generally, characteristics such as age, gender, ethnicity, education level, income, type of client, years of experience, location, etc. are being considered as socio-demographics and are being asked in all kinds of surveys.
2.2	LITERATURE REVIEW
2.2.0. Social demographic factors that affect nurses/midwives triage decision making and triage accuracy in emergency and maternity department
The Influence of Personal Factors on Nurses triage decision-making: Numerous researches have explored the nurses’ personal factors that influencing on decision-making, the quality of nurses’ response and decision-making about triage for patients’ cares are varies according to their knowledge, experiences, and skills. Understanding the influencing factors of nurses’ triage decision-making skills can improve nurses’ clinical practice in order to provide safe and high-quality patient care.
 2.2.1. Factors affecting nurses/midwives triage decision making and triage accuracy
Many literatures say that triage is the best way to deal with overcrowding found in hospital emergency department which has been a challenge for nurses who are trying to provide a high quality of care for patients  (Noon,et,al , 2014). To face this challenge, the sorting of patient was found to be important  (Marsden,et,al, 2008)and that sorting is what we call triage while the process of assessing patients to make a triage decision is called triage decision making.
Emergency nurses often find themselves doing triage under time pressure and with only limited information (Reay et al, 2013), while the accuracy of triage assessment may well determine a patient’s safety.
Many studies say that there exist different factors that may affect or influence nurse’s triage decision making (. Croskerry, et,al, 2009) Suggested that “all decisions are made in some sort of context”, therefore clinicians’ decision making may be influenced by such contextual factors.
Many literatures say that factors related to triage decision making for nurses are knowledge and skills, education level, working experience, and training  (Kerie S et.al. , 2017).
These factors lead to positive attitude, better communication and performance in the hospital  (Mwachofi A et.al., 2011),Sufficient knowledge of nurses ‘is supported by the participation of several trainings related to triage decision making, which includes Emergency Disasters Management , BLS, BTLS, and ECG resuscitation training  (McCarthy L et.al., 2010).Triage knowledge refers to the level of factual and procedural understanding needed by emergency nurses to conduct rapid assessments, patient categorization, and allocation  (Andersson A et.al., 2006). Other studies say that Nurses with more than five years of experience are considered better in the triage decision-making process  (Qureshi NA, et.al, 2010). 

Nurses with more years of experience are more secure in deciding on patients’ priorities and intuition is developed through a long experience that helps decide the actual condition of the patient  (Fathoni M et.al, 2015) Hicks in America have been also reported that increase of experience, increases decision-making stability in emergency triage situation (Hicks et al., , 2003). 
Several studies reported that continuous education and training is the foundation of a triage system and contributes greatly to decision making (Hoyt KS et.al. 2007). Other studies show that unit crowdedness i.e. high number of patient in an emergency department, and the personnel’s work volume have an impact on emergency nurses ‘triage decision and triage accuracy (Fry et al,2001). The other factor that has been identified as having influence on triage decision-making is the work environment and availability of equipment. 

Moreover, time pressure was also reported to be negatively affecting nurses’ decision performance. Align with this; Wolf suggests a framework where integration between personal capacity, ethical consideration, and environment factors may influence nurses’ triage decisions. Based on this framework, it seems that triage is not as simple as sorting patients based on their acuity, but it does involve those factors in decision-making process (Wolf,et,al, 2013).

As an example of interaction between these factors, nurses may lack good communication skills, critical thinking skills, ability to work under stress and confidence in their actions because they are concerned about being judged by patient or other nurses, this may lead them to make an accurate or inaccurate triage decision, although it may not match with their clinical judgment.   
Moreover, when nurses have to decide which patients might need immediate treatment in the emergency department, they need to communicate with patients or their family to gather subjective data. They must also be fully aware of the number of beds available and how many health personnel they can call upon. Therefore, communication between triage nurses and other staff in a hospital’s emergency department should be established effectively for accurate triaging  (Epstein, , 2013).  
	
2.2.2. TRIAGE TYPES AND SYSTEMS
As noted above, triage in its primary sense is the sorting of patients for treatment in situations of at least modest resource scarcity, according to an assessment of the patient’s medical condition and the application of an established sorting system or plan. Defined in this way, the most common types of triages include ED triage, inpatient (ICU) triage, incident (multicasualty) triage, military (battlefield) triage, and disaster (mass casualty) triage. (Elbaih A. H., 2019)
Although each of these types of triages has distinctive elements, all of them satisfy the 3 basic conditions for triage described above, and some have additional features in common. (Ali, 2013)
One can, in fact, represent the types of triages as points on a continuum from relatively resource-rich situations in a stable social environment, as in EDs, to the almost total lack of resources and social chaos experienced during or after severe widespread disasters. This continuum is based on the ratio of resources to the number of patients who must be evaluated and treated simultaneously.  (Profile, 2020)
2.2.2.1. Emergency department Triage
In modern US, Emergency departments triage officers (usually nurses), routinely assess all patients who present for treatment to sort and prioritize them. ED triage systems are typically designed to identify the most urgent (or potentially most serious) cases to ensure that they receive priority treatment, followed by the less urgent cases. In routine ED triage, resources are available to treat every patient, although those who are less severely ill or injured must wait longer.  (Perrin, Kathleen Ouimet, 2020)
Some ED triage systems are designed to identify patients with very minor problems and refer them for treatment at clinics or by their own physicians Commentators have criticized this practice as both morally and medically perilous for routine on-site triage, EDs in the United States generally use a 3-level system, although 5-level systems are gaining acceptance as they prove themselves to be more reliable. (Safari, 2012)
Figure 1: level of triage systems
Other countries, such as Canada, Spain, the United Kingdom, and Australia, have already adopted 5-level systems for ED use. Several methods of 5-level triage are in use. The Emergency Severity Index, developed in the United States, designates the most acutely ill patients as level 1 (highest level) or 2 and uses the number of resources a patient needs to determine levels 3 to 5 (lowest level).The Manchester Triage Scale, used widely in Great Britain, uses 52 algorithms based on the patient’s chief complaint to determine the triage level.3, 5. (Twagirayezu, Innocent, 2021)
The Canadian Triage and Acuity Scale use an extensive list of clinical descriptors to place patients in one of 5 triage levels. Each level has an associated time required for physician assessment, with all level 1 patients needing to be treated immediately. 
These methods have well, but not excellent, interpreter reliability, making it unclear whether these are flawed systems, whether those using them are not up to the task, or whether other-than-medical criteria are influencing some decisions Inpatient  (Lampi, 2017)
2.2.2.2. Intensive Care Unit (ICU) Triage
When a patient requires hospitalization, additional decisions must be made about what level of hospital care the patient should receive. In the optimal situation with abundant hospital resources, the patient can immediately receive any and all services that reason suggests may be beneficial. In the more common situation of relative scarcity of at least some hospital-based resources, decisions must be made about who will receive priority access to those services. If these decisions are based on assessment of the patient’s condition and are made according to some system or plan, they are triage decisions. The most common inpatient triage decisions in US hospitals involve access to intensive care. (Pratiwi, et,el, 2020)
 In theory, these decisions allocate ICU beds to those who can most benefit from this level of treatment. In less affluent nations with limited hospital services, Inpatient triage decisions are routinely made about priority access to surgery and diagnostic imaging, as well as intensive care. (Ali, Sardar,et,el, 2013)
Another system used in casualty situations is an example of advanced triage implemented by nurses and other professionals. This advanced triage system incorporates a colour coding scheme for red, yellow, green, white and black markers.
Red marker :( immediate) is used to mark a person who needs immediate resuscitation 
Orange Marker: who need resuscitation but not immediately
Yellow Marker :( Observation) People in need of observation (and may be re triaged later). Their condition is now stable and their lives are not in imminent risk. These victims continue to require hospital care and are treated immediately under normal circumstances. 
The green marker :( waiting) is reserved for “walking injuries" that ultimately need medical care after a more serious injury has been treated.  
White mark-(dismissal) is given to a person with minor injuries who does not need to see a doctor. 
Black Tag-Used by the (becoming) deceased and those who are injured so extensively that they cannot survive given the care available. (Elbaih A. H., 2019)
 
2.3.0. Empirical literature on social demographic factors influencing nurses and midwives’ triage decision-making process
Age and gender
Nurses’ demographic factors such as gender, age, and race were found to influence the triage clinical decision making. The nurses’ age in some studies had a negative effect on nurses’ ability to make patient care decisions, or a positive effect in an emergency case the more you became elderly more you lose attention in clinical decision making  ,  when you are young in ages more  you  participation in the Clinical decision making and more concentrated in triage decision making . Likewise with nurses’ gender, there was a significant difference in the male and female nurses score in terms of Clinical Decision Making, as the maximum mean score belonged to male nurses in some previous studies(Ham et al., 2008) . found that less experienced male nurses' decision-making scores were similar to female nurses' scores who had more than ten years of working experience, which indicate that male gender perceived different models of decision making proceed.
Working experience: 	
Several studies found that nurse's experience has a major influence on nurse ‘decision-making (Tam et al., 2018) found that the previous clinical experience would work as a valuable reference for the nurses in the clinical settings. According to Ham et al., (2017) the most mentioned factor that influence nurses’ and midwives decision-making in nursing literature was the clinical experience .
 These findings confirmed by Nibbelink & Brewer, (2017) indicating that nursing experience in clinical settings represented the largest impact in the Decision making Process in nursing literature. Similarly, Salami et al., (2017), found that experienced nurses had the power to take some risky non-nursing decisions and the power to question the physicians about their treatment decisions.
Experience increase nurses’ power degree, confidence level and their awareness about the taken decisions. Nurses believed experience as a vital factor influencing the decision-making of post myocardial infarction care. However, the result of (Ham et al., 2008)indicated that experienced and less experienced nurses were similar in planning the nursing interventions in relation to decision-making regardless of their level of expertise.
Autonomy
Nurses' ability to make sound decisions require having professional autonomy in patient care and greater participation in organizational decisions .This study supports evidence from previous study findings of (Ugur et al., 2015) who found a positive relation for nurse’s length of experience and decision-making autonomy.
 Nurses who have been working for (10-20 years) were showing a higher autonomy level more than other nurses who had lesser years of experience. Also, nurses in the burn, delivery room, and emergency units reported higher decision-making autonomy than other nurses who were working in the medical intensive care unit. In addition, Nibbelink & Brewer, (2017) highlighted that autonomy and independence in various nursing interventions would contribute to the clinical decision making process. In contrast to the previous studies, Wu et al., (2016) indicated that having more work flexibility, autonomy and a higher level of formal empowerment could cause significant negative effects for those nurses with weak clinical decision-making ability. As it might impose some psychological load on nurses and consequently hinder their decision-making skills
2.2.2 Factors which affect nurses/midwives triage decision making and triage accuracy
Triage is the point at which emergency care begins (whitby, 1997)Triage decisions are fundamental in determining the trajectory of emergency care (Williams, 1992)  .Accuracy of triage decisions is considered to be a major factor that determines patients, outcomes in the emergency department( (considine, 2007) 
The triage category is important not only in correctly identifying the priority of the needs of a patient but also because it may have implications in the evaluation of the costs of a department.(Williams,et,al, 1996)
It is important that triage is carried out speedily, efficiently, sympathetically, and courteously within somewhat arbitrarily defined patients charter limits (Williams,et,al, 1996).
Emergency nurses require in depth knowledge and clinical expertise to provide care across the lifespan and to manage situations such as patients overcrowding and the use of complex technology (Fry,et,al , 2004). Nurses' knowledge and level of educational certainly influence the decision-making. For instance; (Ugur et al., 2015) presented a significant positive link between the nurse’s educational level and their decision making ability .This finding seemed to be consistent with other research which found that nurses who were holding a bachelor's degree and other critical care certificates were able to demonstrate an advanced reasoning skills in clinical triage decisions making ,Likewise, (Wu et al,2016) found a significant result between nurses ‘triage  decision-making skills and the educational level. The nurses who were raising their educational level would be able to make higher effective decisions through building a theory base to guide the decision-making.
A study in Australia found that 75% of the emergency nurses agree that the basic components of triage are rapid assessments, first aid, and prioritization of medical urgency  (Burr, et,al, 2001). A study that was done had showed that experience alone does not result in improved triage decisions  (Wuerz,et,al, 1998).
Although factual knowledge (i.e., knowledge gained through formal training) and knowledge gained from experienced are inextricably linked, factual knowledge appears to play a more important role in triage decisions than years of emergency nursing or triage experience. Factual knowledge has also remained a key influence in triage decisions irrespective of the reason why the Australian emergency nursing association recommended emergency nurses to be prepared for the triage role via structured unit based educational preparation prior to undertaking the triage role  (Malllet,et,al, 1990).

2.3. CONCEPTUAL FRAMEWORK:
A conceptual framework was made based on previous literature reviews about factors affecting nurse/midwives triage decision making and triage accuracy as shown in Figure below,
In this conceptual framework access to factors affecting nurse/midwives triage decision making are directly related to triage accuracy, these factors and their social demographic data are associated with triage accuracy in emergency and maternity in Kibogora district hospital.

Reduced hospitals overcrowding
Quick admission to Intensive Care Unit (ICU), in- hospital  
Reduced mortality rate to the patients through early intervention
Early discharge diagnosis.

INDEPENDENT VARIABLES         DEPENDENT VARIABLES                OUTCOMES 

Triage accuracy 
Triage decision making

Age
Gender
Working service 
Job title 
Qualification
Working experience 

                                                                 

Figure 2: Conceptual frame work adapted from Ajzen and Fischbein, 1980) 

CHAPTER THREE: RESEARCH DESIGN AND METHODOLOGY

3.0 INTRODUCTION
The present chapter is describing the methodological approach that was used to conduct the research. It includes the study area, study design and approach, study population and sample size, data collection tool and procedure, ethical consideration, data analysis, reliability, and validity measures.
    3.1 RESEARCH APPROACH AND STUDY DESIGN
In this research, non-experimental quantitative approach was used to determine the factors affecting Nurses/Midwives triage decision making and triage accuracy. Quantitative methods emphasize objective measurements and the statistical, mathematical, or numerical analysis of data collected through polls, questionnaires, and surveys, or by manipulating pre-existing statistical data using computational techniques. Quantitative research focuses on gathering numerical data and generalizing it, across groups of people or to explain a particular phenomenon.
A research design is a strategy that is used to find responses to research questions and specify the variables to be considered, the type of data which are to be collected, the methods and the time of data collection (Rahi, 2017). A descriptive cross-sectional design was used to assess factors affecting nurse/midwives triage decision making and triage accuracy in emergency/maternity at Kibogora district hospital. 
3.2 TARGET POPULATION
This study was composed by a total of 37 nurses and midwives working in emergency and maternity services at Kibogora District Hospital who met the eligibility criteria. The setting area was chosen because it is a hospital which is located near our school and while we were in clinical practice in Kibogora hospital, we have seen that there were gaps in how nurses and midwives do triage and based on the data collected in that hospital about the effectiveness of triage in 2021 we have seen that triage were not done effectively and we were wondering to know if there were factors which might be affecting triage decision making and accuracy in the mentioned hospital.
3.3. SAMPLING PROCEDURE
In this research a non-probability convenience sampling method was used in the selection of samples. A non-probability sampling is a sampling technique where the probability of any member being selected for a sample cannot be calculated.(Steinmetz, 2016).The selection was including all nurses/midwives working in emergency and maternity departments at Kibogora district hospital.
3.4 SAMPLE SIZE	
The sample size was composed by 17 nurses who were working in emergency and 17 midwives who were working in maternity department during the time of our study. 
n=N/ [1+N (e) 2], where n = stands for sample size, N: is the size of the population and e: sampling error =+/-5% (Madow, 1968)
Where n= 37/1+37(0.05)2
=34
3.4.1. Inclusion criteria
All registered nurses and midwives who were working in emergency and maternity department and who signed consent form for participating in this study were included.
3.4.2 Exclusion criteria
All registered nurses and midwives who were not working in emergency or maternity, those who didn’t sign the consent form so that they can participate in the study and those who were not present during the period of data collection.
3.5 RESEARCH INSTRUMENTS FOR DATA COLLECTION
A structured questionnaire consisted of three sections was used to find out /to assess factors affecting nurses/midwives’ triage decision making and triage accuracy in emergency and maternity at Kibogora District Hospital. Every section was consisted of a set of structured questions developed using a simple language that respondent were able to understand so that they completed it without researcher’s assistance in order to minimize biases during data collection. 
The questionnaire was developed in two languages used in Rwanda, which were Kinyarwanda and English to minimize the barriers of communication and understanding to the respondents.

3.6 DATA COLLECTION PROCEDURES
After receiving the ethical approval from Kibogora Polytechnic school we had applied for permission to conduct research from Kibogora District Hospital ethical committee. Once permission was granted, We met with the head of departments of Kibogora District Hospital‘s emergency/maternity service to introduce ourselves, we explained the study purpose and we asked permission/consent to conduct study in those departments The participants who agreed to participate in  the study  signed the consent form writen in Kinyarwanda or English according to participants preferred language, then we administered questionnaires to the respondents. 
The questionnaire were composed by 3 sections. Section one was composed by questions regarding socio demographic factors which affect triage decision making and triage accuracy; section two were composed by factors affecting triage decision making and section three was composed by factors affecting triage accuracy among nurses and midwives working in emergency and maternity service at kibogora district hospital. The respondants gave back the completed questionnaires to us after completion and this process  took about 2 month so that we found the time to reach to all nurses/midwives working in emergency and maternity departments who accepted to participate in the study.
3.7 ETHICAL CONSIDERATIONS
The clearance to conduct the study from Kibogora polytechnic was requested by the researcher and was submitted to Kibogora district hospital administration for authorization of carrying out our research. The participation was voluntary and confidentiality. Names of the participants were not supposed to appear on questionnaire and consent was obtained from participants before data collection. There was no harm or loss of any benefit for the participants who refuse to participate in our study. 
3.8 DATA ANALYSIS
Focuses on analyzing respondent’s views about the factors affecting nurse/midwives triage decision making and triage accuracy and data analysis had guided by SPSS version 26 software.

3.9 RELIABILITY AND VALIDITY MEASURES	
Validity and reliability are the major criteria for measuring the instrument quality and adequacy.
Reliability
Reliability is the consistency of an instrument or a measure. In this study, the questionnaire was pre-tested in 10 nurses/midwives who work in emergency and maternity at Kibogora district hospital in order to assess the reliability of the research instruments.
Validity
Items of the questionnaire were covering all objectives of the research. A questionnaire was observed to see whether is complete; data entry had been accomplished and analyzed to see whether the aims and objectives of the study were achievable. Adjustments were made accordingly, in case required, with the guidance of the supervisor

CHAPTER FOUR: DATA PRESENTATION, ANALYSIS, INTERPRETATION AND SUMMARY
4.0 INTRODUCTION 
In this chapter, the results of the study on factors affecting triage decision making and triage accuracy among nurses/midwives working in emergency departments of Kibogora District Hospital were presented, analyzed and interpreted. This chapter also includes the discussion of the results and this was guided by the objectives of the study. The chapter ends up by the summary of the findings. The data analysis was done by using statistical package for social sciences (SPSS) software, version 26, and the results were presented using descriptive statistics in the form of tables. 
4. 1 DATA PRESENTATION AND ANALYSIS
4.1.0. Description of participant’s demographic data 
The majority of participants in gender were female with 52.9% (n=18), then male were minimum with 47.1% (n=16). In ages the high number of participant were 20-39 years old with 70.6% (n=24) and the low participant were 40-59 years old with 29.4% (n=10). By working service of emergency and maternity all participant attending were equal, with 50% (n=17) each. In job title high participant were nurse with 58.8% (n=20) and low participant were midwives with 41.2% (n=14).
In Qualification high participant were having advanced diploma A1 with 88.4% (n=28) followed by bachelor’s degree with 11.8% (n=4) then low participant were having diploma certificate A2 with 5.9% (n=2). Lastly there was working experience, where high number of participant have 4-6 years of experience with 35.3% (n=12); followed by 1-4 years’ experience and10-14 years all has 23.5% each (n=8) and low participant were those with 15 years and above of working experience had 5.9% (n=2). 

Table 1 Socio-demographic characteristics of the participants

Variables	Frequency (n=34)	Percent (%)	
Gender
Male
Female
	
16
18
	
47.1
52.9
	
Age
20-39
40-59
	
24
10
	
70.6
29.4
	
Working service
   Emergency
   Maternity
	
17
17
	
50
50
	
Job title
  Nurse
  Midwife
	
20
14
	
58.8
41.2
	
Qualification
  Bachelor degree
  Advanced diploma degree
  Diploma/certificate A2
	
4
28
2
	
11.8
82.4
5.9
	
Working Experience
   1-4 years
   4-6 years
   7-9 years
   10-14 years
   15 years and above
	
8
12
4
8
2
	
23.5
35.3
11.8
23.5
5.9

4.1.1. Description of factors affecting nurses/midwives triage decision making 
The results showed that triage policy awareness and triage practice were effective with 100% (n=34) in all participant. 
Knowledge on triage practice, good with high percentage of 88.4% (n=28), and bad has low percentage of 17.6% (n=6). Participants agreed that sufficient knowledge and skills affect triage decision with 94.1% (n=32) and only 5.9% (N=2) said no. Working experience was affecting triage decision where high number of participants said yes on a percentage of 73.5% (n=25) and low number of 26.5% (n=9). 
High number of participant accepted that having training on BTLS, BLS and ECG use have an impact on triage decision making where79.4%(n=27) said yes and low number said no 20.6% (n=7). And we have seen that many participants got training in basic life save with 88.2% (n=30) while only 11.8% (n=4) didn’t get the training. High numbers of participant said that their last training in BLS was between1-6 months with 73.6% (n=25), followed by those with 6-12 months with 14.7% (n=5) and only a small number of participant said that it has been 5 years and above since their last training in BLS with 2.9% (n=1).
High number of participants accept with 91.2% (n=31) that working environment affect triage decision and other low number say no with 8.8% (n=3). High number of participants accept that availability of medical equipments affect triage decision with 91.2% (n=31) and small number said that there was no effect on decision making with 8.8% (n=3) even though  high number of participants said that those machines were not enough with 61.8% (n=21) and others said that they were enough and good functioning with 38.2%.
Many of participants accepted that communication skills affect triage decision making with 88.2% (n=30) and small number said no 11.8% (n=4) thinking that there was no effect on triage decision. 

Table 2 description of factors affecting nurses/midwives triage decision making
Items 	Frequency (n=34)
	Percent (%)
	
Triage policy awareness
  Yes
  no 	
34
0
	
100
0
	
Triage practice
  Yes
  No
	
34
0
	
100
0	
Knowledge on triage practice
  Bad
  Good
	
6
28
	
17.6
82.4
	
Sufficient knowledge and skills affect triage decision?
   Yes
   No

32
2

94.1
5.9
	
Working experience affect triage decision?
  Yes
  No 

25
9

73.5
26.5

Training on BTLS, BLS and ECG resuscitation?
  Yes
  No

27
7

79.4
20.6
	
Did you have training in BLS?
  Yes
  No
	
30
4
	
88.2
11.8
	
How long was the last training in BLS?
  1-6 months
  6-12 months
  1-2 years
  5 years and above

25
5
3
1
	
73.6
14.7
8.8
2.9
	
Level of education affects triage decision?
  Yes
  No

20
14

58.8
41.2
	
Working environment affect triage decision?
  Yes
  No

31
3

91.2
8.8
	
Availability of Medical equipment affects triage decision?
  Yes
  No

31
3

91.2
8.8
	
CTG machine, vital signs monitors, ECG machine are available?
  Yes
  No

22
12

64.7
35.3
	
Those machines are enough and good functioning?
  Yes
  No

13
21

38.2
61.8
	
Communication skills affect triage decision?
   Yes
   No

30
4

88.2
11.8
	
How is your communication skill?
   Bad
   Good

3
31

8.8
91.2

4.1.2. Factors affecting triage accuracy among nurses/midwives working in emergency and maternity in Kibogora district hospital.
The results showed that high number of participants supported that triage accuracy can be affected by unity overcrowdings/patient overload with 88.2% (n=30) said yes and low number said no with 11.8% (n=4); about Triage accuracy cannot be affected by work space limitation large number accepted it with 61.8% (n=21) and other small number of participants said no with 38.2% (n=13).In this field of study many participants said, it’s that true triage accuracy cannot be affected by shortage of nurse / midwives with 58.8% (n=20) and small number of participants say no 41.2% (n=14). About Poor staff allocation may affect triage accuracy many of participants accepted it with 67.6% (n=23) and then other small number said no with 32.4% (n=11).
This study also showed that Poor communication may affect triage accuracy where high number of participants accepted it with 85.3% (n=29) and small number said no with 14.7% (n=5). And also shows that Good critical thinking is key for triage accuracy; Nurse / midwives must have the ability to work under stress; Lack of confidence and negligence are bad behavior associated with poor triage accuracy; Working under stress with limited time cannot affect triage accuracy and lastly Limited beds or insufficient beds have negative impact on triage accuracy many participant are accept as the most factors affecting nurse/ midwives triage accuracy where high number of participant said yes with 70.6% (n=24);52.9% (n=18);82.4% (n=28); 52.9% (n=18) and 73.5% (n=25) respectively . And then other small number of participants said no with 29.4% (n=10); 47.1% (n=16); 17.6 % (n=6); 47.1 % (n=16) and lastly 26.5% (n=9) respectively.
Table 3 Factors affecting triage accuracy among nurses/midwives working in emergency and maternity at Kibogora district hospital.
Items	Frequency (n=34)	Percentage (%)	
Triage accuracy can be affected by unity overcrowdings/patient overload?
 
Yes
 No

30
4

88.2
11.8
	
Triage accuracy cannot be affected by work space limitation?
  Yes
  No

21
13

61.8
38.2
	
Triage accuracy cannot affect by shortage of nurse / midwives?
   Yes
   No	

20
14

58.8
41.2
	
Poor staff allocation may affect triage accuracy?
 Yes
 No	

23
11

67.6
32.4
	
Poor communication can affect triage accuracy?
  
Yes
 No

29
5

85.3
14.7
	
Good critical thinking is a key for triage accuracy?
  
Yes
 No

24
10

70.6
29.4
	
Nurse / midwives must have the ability to work under stress?
  
Yes
 No

18
16

52.9
47.1
	
Lack of confidence and negligence are bad behavior associated with poor triage accuracy?
  Yes
  No

28
6

82.4
17.6
	
Working under stress with limited time cannot affect triage accuracy?
  Yes
  No

18
16

52.9
47.1
	
Limited beds or insufficient beds have negative impact on triage accuracy?
  Yes
  No	

25
9

73.5
26.5

4.2.1. The correlation between socio-demographic data and factors affecting triage accuracy.
The table below shows the relationship between socio-demographic data and factors affecting nurses/midwives triage accuracy. Those which were having significance between socio- demographic data and factors affecting nurses/midwives triage accuracy are those with p-value less than 0.05 and those were gender with a p-value of 0.014 , job title with a p value of 0.035  and qualification with p-value of  0.021. Other social demographic factors like age and working service with p -values of 0.714 and 0.148 respectively, have no significant relationship with factors affecting nurse/midwives triage accuracy.
Table 3 The correlation between socio - demographic data and factors affecting triage accuracy
Social-demographic characteristics               	                    Correlation	

Age	Effect of social demographic characters to factors affecting triage accuracy.	
	accepting utilization  	rejecting utilization    	test used                   	p-value	
	 n  	  %  	N	 %	

Fischer test           	

0.714	
<20                             	0	0	0	0			
20-39 years                               	16	47.05	8		23.52			
40-59 years	6	17.64	4	11.76			
60-above	0	0	0	0			
     
 Gender  
	
Male	7	20.58	9	26.47	Fischer test           	
0.014	
Female	15	44.11	3	8.82			

			

				
Working service  		
Emergency	9	      26.47	8	23.52	Fischer test           	0.148

	
Maternity	13	38.23	4	11.76			

							
Job title  	
Nurse 	10	     29.41	10	29.41	
Fischer test        	
0.035	
Midwives  	12	35.29	2	5.88			

						

Qualification 	
Doctoral degree	0	0	0	0	
Fischer test           	 
0.021	
Master’s degree	0	0	0	0			
Bachelor’s degree	4	11.76	0	0			
Advanced diploma	18	52.94	10	29.41			
Diploma A2               0        0         2          5.88	
Working experience	
<1 years                   0        0         0            0	
1-3 years                  5        14.7      3           8.82       Fischer test 0.82	
4-6 years                  7        20.58     5           14.7	
7-9 years                  4        11.76     0            0	
10-14 years                6        17.64     2           5.88	
15years and above         0       0          2           5.88	
	
4.2.2. The correlation between factors affecting nurses/ midwives triage decision making and factors affecting nurse/midwives triage accuracy in kibogora district hospital.
The table below shows the relationship between factors affecting nurses/midwives triage decision making and triage accuracy in kibogora district hospital. They are those factors with p-value less than 0.05. those are level of education with a p-value of 0.023 being motivated with p-vale of 0.029, impact of availability of medical equipment with a p-value of 0.016 and availability of CTG machines, vital signs monitors and ECG machine with a p- value of 0.048, these values shows that there is significance between factors affecting nurses/midwives triage decision making and triage accuracy. 
Other factors affecting nurses/midwives triage decision making like knowledge on triage practice with a P value of 0.444; sufficient knowledge and skills with a p-value of 0.163 ; working experience with a p-value of 0.733 ; training on (BTLS, BLS, ECG resuscitation) with a p-value of 0.889; trained in BLS with a p-value of 0.943; on how long was the last BLS training session with a p-value of 0.334 ; working environment with a p-value of 0.783; machine enough and good functioning with a p-value of 0.217; communication skills with a p-value of 0.104 lastly is how they communicate with p-value of 0.163. Those values show that there is no significant relationship between factors affecting nurse/midwives triage decision making and triage accuracy.
Table 4 Correlation between factors affecting nurses/ midwives triage decision making and factors affecting nurse/midwives triage accuracy in kibogora district hospital.
Factors affecting nurse and midwives triage decision.               	                    Correlation	

Triage policy awareness
	Effect of factors affecting triage accuracy to factors affecting nurses/midwives triage decision making.	
	accepting utilization  	rejecting utilization    	test used                   	p-value	
	 n  	  %  	N	 %	

Fischer  test        

All Are aware	
yes                            	25	73.52	9	26.47			
no                               	0	0	0	0			
							
Triage practice
 	
Yes	25	73.52	9	26.47	Fischer test           	
All are practice 	
No	0	0	0	0			

			

				
Knowledge on triage practice		
Bad 	1	      2.94	1	2.94	Fischer test           	0.444

	
Good 	24	 70.58	8	23.52			

							
Sufficient knowledge and 
Skills affect triage decision?  

Yes	22	   64.7	9	26.47	
Fischer test        	
0.163	
no  	3	8.82	0          	0			

Working experience 
Affect triage decision?
  	
Yes	18	52.94	7	20.58	
Fischer test           	 
0.733	
No 	7	20.58	2	5.88			

Having training on BTLS, 
BLS and ECG use
 	
Yes                        20       58.82        7           20.58	
No                         5        14.7         2           5.88    Fischer test 0.889 	
Did you got training in BLS?
                                       	
 Yes                       22         64.7        8         23.52    Fischer test 0.943	
 No                        3          8.82        1         2.94	
How long was the last training in BLS?	
  1-6 months              17        50         8        23.52	
  6-12 months             4        11.76       1        2.94     Fischer test 0.334	
  1-2 years                3        8.82        0         0	
  5 years and above         1        2.94        0          0	
Level of education affects 
Triage decision?	
  Yes                    12       35.29        8        23.52   Fischer test 0.023	
  No                    13       38.23        1         2.94	
Being motivated impact 
the way you do triage?	
Yes                      13       38.23        9        26.47   Fischer test 0.029	
No                      12       35.29        0         0	
Working environment affect 
Triage decision?	
  Yes                    23       67.64       8       23.52      Fischer test 0.783	
  No                     2       5.88        1        2.94	
Availability of Medical 
equipment affects triage
 Decision?	
  Yes                     22       64.7       9       26.47    Fischer test 0.016
	
  No                      3       8.82       0         0	
Availability of CTG machines, vital signs 
Monitors, ECG machine affect triage decision making?	
  Yes                     5        14.7       5        14.7   Fischer test 0.048   	
  No                     20       58.82       4       11.76	
Those machines are enough and good functioning?	
  Yes                    8        23.52         5        14.7   Fischer test 0.217 	
  No                    17        50           4        11.76	
Communication skills affect triage decision?	
   Yes                  21         61.76        9       26.47     Fischer test 0.104	
   No                   4         11.76        0        0	
How your communication skills?	
   Bad                   3         8.82           0        0    Fischer test 0.163	
   Good                 22         64.7           9       26.47

4.3. DISCUSSION OF FINDINGS
4.3.0. Discussion of social demographic factors which affect triage decision making and triage accuracy
The current study had showed that a majority of participants in gender category was female with 52.9% (n=18), then male are minimum with 47.1% (n=16).this study is similarly to the study conducted in Tanzania had showed that 62% was female, This study also had showed that ages the high participant were 20-39 years old with 70.6% (n=24) and then low participant are 40-59 years old with 29.4% (n=10). Nurses’ demographic factors such as gender, age, and race were found to influence the clinical decision making. Likewise with nurses’ gender, there was a significant difference in the male and female nurse’s score in terms of Clinical Decision Making, as the maximum mean score belonged to male nurses in some previous studies (Bjørk & Hamilton, 2011)
 Present study showed that educational level are advanced diploma A1 with 88.4% (n=28) followed by bachelor’s degree with 11.8% (n=4) then low participant are diploma/ certificate A2 with 5.9% (n=2). Similar study conducted by Hamilton showed that Nurses' knowledge and level of educational certainly influence the decision-making. For instance; (Bjørk & Hamilton, 2011) presented a significant positive link between the nurse’s educational level and their decision making ability .This finding seemed to be consistent with other research which found that nurses who were holding a bachelor's degree and other critical care certificates were able to demonstrate an advanced reasoning skills in clinical decisions. Likewise, (Khan et al., 2016) found a significant result between nurses' decision making skills and the educational level. The nurses who were raising their educational level would be able to make higher effective decisions through building a theory base to guide the decision-making.
Present study continue to show that working experience, high participant are 4-6 years’ experience with 35.3% (n=12); followed by 1-4 years’ experience and10-14 years all has 23.5% each (n=8) and with low participant are those with 15 years and above experience has 5.9% (n=2).  In the study of Cone and Murray from America experience and being an expert were reported as the most important factors affecting triage nurses’ decision-making. Several studies found that nurse's experience has a major influence on nurse ‘decision-making (Khan et al., 2016)found that the previous clinical experience would work as a valuable reference for the nurses in the clinical settings. According to(Khan et al., 2016) the most mentioned factor that influence nurses’ and midwives decision-making in nursing literature was the clinical experience. These findings confirmed by (Khan et al., 2016) indicating that nursing experience in clinical settings represented the largest impact in the Decision Making Practice in nursing literature. Similarly,(Khan et al., 2016), found that experienced nurses had the power to take some risky non-nursing decisions and the power to question the physicians about their treatment decisions.
4.3.1. Discussion of Factors affecting nurse/midwives triage decision making and triage accuracy at Kibogora district hospital
The current study showed that good working environment enhance triage decision making as majority of nurses/midwives agree at a rate of 91.2% (n=31) and majority of respondents showed that availability of material affect triage decision at rate of 91.2% (n=31 and also Many of participants accept that communication skills affect triage decision making with 88.2% (n=30). This is similar to the study conducted by (Gorick H et al., 2022) which shows  that Nurses/midwives triage decisions are influenced by several factors relating to the patient, the nurse, the triage algorithm and the environment where triage takes place (Profile, S E E, 2022) . Nurses’ ability to triage patients accurately is negatively affected by high patient numbers, inadequate staffing levels, lack of privacy and lack of training (Profile, S E E, 2022).
A study conducted in Taiwan had shown that factors related to triage decision making for nurses are knowledge and skills, education level, working experience, and training  (Kerie S et.al. , 2017). Those studies doesn’t contradict to current study because the current study had showed that triage policy awareness and triage practice are effective with 100% (n=34) in all participant and knowledge on triage practice was highest at rate of 82.4% (n=28), majority of participants accept that sufficient knowledge and skills affect triage decision at a rate of 94.1% (n=32) , Also the Impact of Training on BTLS, BLS and ECG resuscitation affect triage decision at a rate of 79.4% (n=27).These factors lead to positive attitude, better communication and good performance in the hospital ((Mwachofi A et.al., 2011),Sufficient knowledge of nurses ‘is supported by the participation of several trainings related to triage decision making, which includes Emergency Disasters Management, BLS, BTLS, and ECG resuscitation training (McCarthy L et.al., 2010).Triage knowledge refers to the level of factual and procedural understanding needed by emergency nurses to conduct rapid assessments, patient categorization, and allocation (Andersson A et.al., 2006). 
The current study continue to show that Working experience affect triage decision at highest modality of 73.5% (n=25) , similarly to the study conducted by (Fathoni M et.al, 2015) which shows that  Nurses with more than five years of experience are considered better in the triage decision-making process (Qureshi NA, et.al, 2010). Nurses with more years of experience are more secure in deciding on patients’ priorities and intuition is developed through a long experience that helps decide the actual condition of the patient.  Hicks in America have been also reported that increase of experience, increases decision-making stability in emergency triage situation (Hicks et al., , 2003). Several studies reported that continuous education and training is the foundation of a triage system and contributes greatly to decision making (Hoyt KS et.al. 2007). Other studies show that unit crowdedness i.e. high number of patient in an emergency department, and the personnel’s work volume have an impact on emergency nurses ‘triage decision and triage accuracy (Fry et al,2001).The other factor that has been identified as having influence on triage decision-making is the work environment and availability of equipment. 
The current study had showed that triage accuracy among nurses/midwives working in emergency and maternity in Kibogora district hospital majority of participant support that Triage accuracy can be affected by unity overcrowdings/patient overload with 88.2% and the remaining had disagreed with it 11.8%. About Triage accuracy cannot be affected by work space limitation large number accept it with 61.8% and other small number of participants had refused with 38.2%.
Similar study had supported this current study, for example study conducted in Tanzania had showed that Emergency Medicine Department receives many patients at rate of 82.5% with different situation requiring urgent attention. (Janssen et al., 2011).
The current study had also showed that triage accuracy cannot be affected by shortage of nurse / midwives with 58.8% and small number of participants agree with it at rate of 41.2% (n=14).  Poor staff allocation may affect triage accuracy at a rate of 67.6%. This study also shows that Poor communication can affect triage accuracy with high number of participants accept it with 85.3%. This study shows that 70.6% of participants accepted that Good critical thinking is a key for triage accuracy and other small number of participants say no with 29.4% (n=10); 52.9%(n=18)  of participants accept that nurses / midwives must have the ability to work under stress and other small number of participants say no with47.1% (n=16); Lack of confidence and negligence are bad behavior associated with poor triage accuracy were 82.4% (n=28) of the participants agree and other small number of participants say no with 17.6 % (n=6); this study shows that working under stress with limited time cannot affect triage accuracy at a percentage rate of 52.9% where small number of participants said no with a percentage rate of 47.1 % (n=16) and lastly limited beds or insufficient beds have negative impact on triage accuracy where large number of participant  accept it at 73.5% (n=25) and other small number of participants say no at a percentage rate of 26.5% (n=9). 
Those results are similar to the study conducted in Tanzania where the participants also mentioned the need for scope of practice because they were being assigned to duties which were not meant for triage nurses in triage rooms resulting into unnecessary delays in patient care. Similar to previous findings  ((Janssen et al., , 2011), and also poor motivation in terms of payment, appreciation and recognition by the employer were mentioned as negatively impacting on their work resulting into unmet expectations. Another concern from respondents were that some workers lacking positive attitude towards their profession for example triage nurse omitted vital signs documented because some equipment were not functioning although in their basic training, they were taught how to take pulse rate manually. There was also a complaint from participants about triage nurses documenting wrong vital signs, or sending patient to resuscitation room without checking if the patient does meet the criteria.
A similar study conducted in Tanzania had reported that the unbalanced patient staff ratio results into HCWs working overtime and being exhausted thus poor quality of services. Shortage of HCWs has a significant implication in delivering standard care to patients attending the EMD. There were complaints that some triage nurses did not complete the triage form or documenting wrong vital signs, triage nurses did not always carry out triage of every patient arriving at an EMD). The current study Also participants stated that one of the reasons for nurses leaving the unit was heavy workload. So, if there could be enough nurses, brain drain could have been reduced. The hospital need to recruit and hire new employees, it needs to develop strategies to retain workers for example improving working environment, salary increment, acknowledgement, payment of extra duty allowances. This will increase the quality of care delivered but also motivate those on duty.
The study also shows that there is an issue of disagreement among nurses on the criteria for triaging patients to the resuscitation room. Respondents said that they re-triage patients in the resuscitation room for those patients who do not meet the criteria. Emergency management is by team, rather than by individual players, so teamwork should be emphasized and practiced and communication should improve between nurses and doctors It is very important that all nurses and doctors in the department have a similar understanding of the criteria used for triaging according to the ETAT guideline in order to minimized disagreements among HCWs ensuring right management is given at the right time.
In those circumstances it leaves the triage nurse in dilemma to make decision. It is important that there should be a modification in the triage guideline to accommodate some other emergency situation to be functioning appropriately by comparing the existing situation with international standards, and suggesting actions to solve identified problems and to document and evaluate such a process.Managers in the unit need to develop interpersonal and communication skills, appreciating the productivity of their employee and motivate them to do better. Although participants mentioned some difficulties they encounter during triaging, most of respondents recommended the Guideline to continue to be used so that it can help HCWs in their daily activities but also suggested orientation course to the guideline before starting to work at the EMD.
4.3.2. Association between Variables

The current study shows   that social   demographics characteristics and factors affecting triage accuracy have significant relationship. Those which were having significance are those with p-value less than 0.05 and those were gender with a p-value of 0.014, job title with a p value of 0.035 and qualification with p-value of 0.021. 
Other social demographic factors like age and working service with p -values of 0.714 and 0.148 respectively have no significant relationship with factors affecting nurse/midwives triage accuracy. A similarly study   conducted in Australasian College for Emergency Medicine contradict   the   currents    study   because for   total of 42/50 (84%) participants, providing 9946 scenario responses for analysis. Significant differences in concordance were observed by variables describing the type of patient presentation and level of urgency.). There was a significant main effect on concordance by type of service according to demographic group (P= 0.03). Of the nine variables that described nurse characteristics, age was the only factor to influence the outcome (P= 0.05).
This study also showed the relationship between factors affecting nurses/midwives triage decision making and those affecting triage accuracy in kibogora district hospital and those were level of education with a p-value of 0.023 being motivated with p-vale of 0.029, impact of availability of medical equipment with a p-value of 0.016 and availability of CTG machines, vital signs monitors and ECG machine with a p- value of 0.048, these values shows that there is significance relationship between factors affecting nurses/midwives triage decision making and those affecting  triage accuracy.
4.4. SUMMARY OF FINDING 
This   study was conducted in 34 nurses/midwives who were working in emergency and maternity department of Kibogora district hospital. It show that in social demographic data the majority of participants in gender were female with 52.9% (n=18, in ages the high participant were between 20-39 years old with 70.6% (n=24). In Qualification high participant were having advanced diploma A1 with 88.4% , according to working experience high number of participants spent between 4-6 years of experience with 35.3% (n=12).

Even though there were many factors which may affect triage decision making and triage accuracy according to different studies from different researchers, our study showed that demographic factors which were affecting triage decision making and triage accuracy were those with significance association between them as represented by p value < o.o5 and those were gender with a p-value of 0.014, job title with a p value of 0.035 and qualification/ working experience with p-value of 0.021. This study also showed that other factors which were affecting nurses/midwives triage decision making and triage accuracy in kibogora district hospital, were level of education with a p-value of 0.023 being motivated with p-vale of 0.029, impact of availability of medical equipment with a p-value of 0.016 and availability of CTG machines, vital signs monitors and ECG machine with a p- value of 0.048. Other factors which are not mentioned in this summary all were rejecting the utilization and their p values were above 0.05.

CHAPTER FIVE: GENERAL CONCLUSION AND RECOMMENDATIONS

5.0 INTRODUCTION
As previously mentioned in chapter one, this study was aimed to assess factors affecting nurses/midwives triage decision making and triage accuracy in Kibogora district hospital. This chapter presents the study conclusion and recommendations, based on the study objectives and research questions, and the chapter ends up are the suggestions on future research for further studies on factors affecting nurses/midwives triage decision and triage accuracy. 
5.1 CONCLUSIONS
As conclusion, we had seen that triage is the process of determining the priority of patients' treatments based on the severity of their conditions (Fathoni et.al, 2015). Through different literatures we have also seen that congestion and overcrowding of emergency departments (EDs) is a universal and ever-increasing problem worldwide where a triage system have been in place to facilitate the prioritization of patients while providing emergency cares based on their clinical situations.(Edwards et al., 2015). In this study also we found that there were many factors which affect nurses/midwives triage decision and triage accuracy worldwide like knowledge and skills of nurses about hospital emergencies, working experience.
At Kibogora Hospital the factors which were affecting nurses and midwives triage decision making and triage accuracy were level of education with a p-value of 0.023 being motivated with p-value of 0.029, impact of availability of medical equipment with a p-value of 0.016  and availability of CTG machines, vital signs monitors and ECG machine with a p- value of  0.048. We had also found that there were some socio demographic characteristics which were affecting triage accuracy, like gender with a p-value of 0.014, job title with a p value of 0.035 and qualification with a p-value of 0.021. Based on those findings we conclude that Kibogora hospital should find a way to motivate its employees, should avails enough medical equipments and should encourage its employees to keep studying as education level affects the way triage is performed.

5.2 RECOMMENDATIONS

To Kibogora District hospital
As we had seen that triage decision making and triage accuracy in Kibogora hospital was mostly affected by participants level of education, availability of medical equipments and working experience and job qualification, Kibogora hospital need to develop strategies to meet required conditions for triage accuracy like motivating its employees, encourage/facilitate them to continue their studies, improving working environment , avail medical equipments and keep continuous training regarding hospital emergencies and BLS . 
To nursing researchers
Even if triage is a crucial part in emergency department there is still a problem in accuracy of triage due to many factors as mentioned above, reason why we recommend other researchers to do further studies in different hospitals.
To Emergency Staff
We recommend emergency staff to keep into consideration that even if there are still factors affecting triage decision making and accuracy, triage is one of the means which will improve the quality of care given to the clients. Therefore they must perform timely triage every time they are admitting patients.

REFERENCE

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Appendices

QUESTIONNAIRE FORM
Questionnaire designed for Assessing Factors affecting nurses/midwives’ triage decision making and triage accuracy at one district hospital in Nyamasheke.
Instructions
The questionnaires comprise 3 sections and all questions are compulsory:
Section one: is made by Socio-Demographic questions. Fill with√ in the box 
Section two: is composed by questions designed to assess factors affecting Nurses/Midwives triage decision making during emergency triage. Tick √ appropriately in the required box
Section three: is composed by questions designed to assess factors affecting triage accuracy among nurses/midwives working in EDs of Kibogora DH. Fill with T (true) or F (false) in the box.
Section one: Assessment of socio demographic data 
Fill with X or √ in the box or complete where is …….
1.	What is your gender?
Male                             
Female                                
2.	How old are you?  
 <20y.o
Between 20-39y.o
Between 40-59y.o
>60y.o

3.	Which is your working service? 
Emergency 
Maternity  
4.	What is your job title? 
Nurse  
Midwife

5.	What qualification do you have? 
Doctoral degree 
Master’s degree   
Bachelor’s degree  
Advanced Diploma/Certificate (A2) 
Other (Specify)………………
6.	How long is your working experience? 
Less than 1 year   
1 – 3 years        
 4-6 years                 
7-9 years         
10-14 years            
15 years or more 
Section Two: Factors affecting nurses/midwives triage decision making
To complete this section, tick (√) appropriately
1. Are you aware of triage policy found in your hospital?
    Yes
    No
2. Do you practice triage in your hospital?
    Yes
    No
3. How do you practice triage? 
    Bad
    Good
4. Do you think that having sufficient knowledge and skills on emergency nursing can affect the way you make a triage decision?
    Yes
    No
5. Can sufficient knowledge and skills on emergency nursing affect triage decision making positively?
    Yes	
    No

6. Many literatures say that triage decision making is affected by working experience. Do you agree with them?
    Yes	
     No
7. Does having trainings on BTLS, BLS and ECG use a crucial part while making triage decision?
	Yes
	No
8. During your period of work in Emergency or Maternity service did you ever have training on   Basic life support (BLS)?
	Yes
	No
9. For how long was your last training session on BLS
	Between 1-6 months
 	Between 6-12months
	Between 1-2years
	Between 3-5years
	Above 5 years
None
10. Can triage decision making be affected by your level of education?
       Yes
        No

11. Being motivated impact the way you do triage?
      Yes
      No
12. Do you agree that good working environment have a positive impact on nurses/midwives triage decision making
      Yes
      No
13. Does availability of medical equipments like CTG machine, vital signs monitors, etc affect nurses/midwives triage decision making? 
     Yes
     No
14. Are CTG machines, vital signs monitors, ECG machines available in your service?
     Yes
     No
15. Are those machines enough (compared to the patients that you look for) and good functioning?
      Yes
      No
 16. Some Researchers say that good communication skills impact positively nurses triage decision making. Do you agree with them? 
     Yes
     No

17. How is your communication skill? 
      Bad
      Good
Section three: Factors affecting triage accuracy among nurses/midwives working in EDs of Kibogora DH
Fill with T (true) or F (false) in the box
Q1. Triage accuracy can be affected by unit overcrowdness/ patient overload?
Q2. Triage accuracy can’t be affected by work space limitation?
Q3. Triage accuracy can’t be affected by shortage of Nurses/midwives?
Q4. Poor staff allocation may affect triage accuracy?
Q5. Poor communication skills affect triage accuracy?
Q6. Good critical thinking skills are a key for triage accuracy?
Q7. A triage Nurse/Midwife must have ability to work under stress?
Q8. Lack of confidence and Negligence are bad nurses/midwives behaviors associated with poor triage results?
Q9. Working under stress with limited time can’t affect triage accuracy?
Q10. Limited beds or insufficient beds have a negative impact on care delivery to the patient and on triage accuracy?

B. QUESTIONNAIRE: KINYARWANDA VERSION 
INTANGIRO: 1 ibazwa ryateguwe mu gusuzuma ibintu bigira uruhare mugufata umwanzuro uboneye igihe abaforomo n’ababyaza batoranya abarwayi mubitaro bimwe by’ Akarere ka Nyamasheke( kibogora DH)
igice cya mbere:
imyirondoro y’ ubazwa ( uzuza akazu ukoresheje ikimenyetso cya v kumyirondoro ikurikira
1. Igitsina
Gabo
Gore
2. imyaka y’amavuko…….
3 aho akorera
aho bakirira indembe
aho babyarira
4 akazi akora
umuforomo( kazi)
umubyaza

5. impamyabumenyi afite
impamyabumenyi y ikirenga ( doctora)
icyiciro cya gatatu cya kaminuza( masitazi)
icyiciro cya kabiri cya kaminuza( A0)
icyiciro cya mbere cya kaminuza( A 1) 
icyiciro cyambere cy amashuri yisumbuye (A2) 
indi mpamya bumenyi………
6. uburambe mukazi
hasi y’ umwaka
igihe cy’ umwaka( 1-3) 
igihe cy’ imyaka (4-6) 
igihe cy’imyaka(7_9) 
igihe cy’imyaka(10-14) 
igihe cy’imyaka (15 gukomeza)
Icyiciro cya kabiri
Ibintu bigira uruhare mugufata umwanzuro uboneye igihe abaforomo n’ababyaza batoranya abarwayi 
uzuza ukoresheje akamenyetso ka “v”
waba uzi ibwiriza rigena uko abarwayi batoranwa riri mu bitaro ukoreramo? 
Yego
Oya

2. Ujya ukora itoranya rya abarwayi

Yego
Oya
3.  Ni gute uhitamo abarwayi
Nabi
Neza
4. Utekereza ko kugira ubumenyi buhagije mukwakira indebe hari icyo byagufasha mugutoranya abarwayi?
Yego
Oya

5.Ese kugira ubumenyi buhagije mu kwakira indembe bigira ingaruka nziza mugotoranya abarwayi?
Yego
Oya

6. ubushakashatsi bumwe nabumwe bwemeza ko gufata umwanzuro ujyanye no gutoranya abarwayi bigendana nu uburambe bw’umukozi mukazi. Ese wemeranywa nabwo?
Yego
Oya
6.1.)waba waragize amahugurwa ajyanye no kwakira ndetse no gutoranya abarwayi binjiye aho bakirira indembe
Yego
Oya
6.2.)mugihe ukora(wakoraga) aho bakirira indembe & aho babyarira waba warahawe ubufasha bwibanze
Yego
Oya
6.3) umaze igihe kingana gite uhuguriwe gutanga ubutabazi bwibanze
hagati ya amezi (1-6) 
hagati ya amezi(7-12) 
hagati y imyaka( 1-2) 
hagati y imyaka(3-5) 
hejuru y imyaka (5)
7) ese itoranya rya abarwayi mugufata umwanzuro hari icyo bifasha ugendeye kurwego rw amashuri umuntu yaba afite
Yego
Oya
8) ese ubyobozi bundi hari icyo bwaba bugufasha mukukwongera imbaraga muburyo bwo guhitamo umurwayi
Yego
Oya
9) we mera ko gukorera ahantu heza (hateye imbere) bifasha  mugufata umwanzuro no guhitamo umurwayi
Yego
Oya
10) ese mwaba mufite ibikoresho byibanze muguhitamo umurwayi ugendeye ku rwego rw’ubuzima afite
Yego
Oya
11) ubushakashatsi bumwe nabumwe bugaragaza ko kugira ubumenyi mumibanire nabandi nabyo bifasha mukumenya guhitamo  no gufata umwanzuro kumurwayi.
Yego
Oya
SUBIZA UKORESHEJE YEGO (Y) CYANGWA OYA(O)
1) Ese ubwinshi bw’abarwayi bwabangamira ihitamo riboneye? 
2) Ese ihitamo riboneye ntiryabangamirwa naho umuntu akorera( uko hangana)?
3) Ese ihitamo riboneye ntiryabangamirwa n’ubuke bw’ Abaforomo n’ababyaza?
4) Ese kuba abakozi bashyirwa aho gukorera hadakwiriye bishobora gutuma ihitamo     ritagenda neza?
5) Ese ubumenyi budahagije mu isangiramakuru rigira ingaruka ku ihitamo riboneye?
6) Ese imitekerereze yagutse myiza ifasha muguhitamo umurwayi no gufata umwanzuro uboneye? 
7) Ese umuforomo cg umubyaza ukora mu ihitamo ry umurwayi agomba kuba afite ubushobozi bwo gukorera muri stress? 
8) kutigirira icyizere no kudaha agaciro ibyo umuforomo cyangwa umubyaza bakora bituma triage ikorwa nabi? 
9) Gukorera muri stress kdi igihe ari gito nta ngaruka bigira mu gukora ihitamo riboneye?
10) Umubare muke w’ibitanda biri aho bakirira indembe bigira ingaruka mbi kuri service zihabwa abarwayi ndetse no gutoranya abarembye?

C. Informed consent form English Version
Introduction and purpose
Our names are NDAGIJIMANA Jean Pierre and MUKAMUGISHA Dieu Merci Chartine, we are in fifth year of study in general nursing and we are pursuing bachelor’s degree in nursing at Kibogora Polytechnic University. We are conducting a research and its purpose is to Assess factors affecting nurses/midwives’ triage decision making and triage accuracy in Emergency and maternity departments of Kibogora District hospital. 
Thank you for agreeing to take part in this research, your participation will be very helpful.
Procedures
If you agree to participate in this study, you will be given a questionnaire which you will be asked to answer.
Risks
There are no known risks or harm that may result from taking part in this study.
Compensation: No monetary or material benefit will be given to the subjects for participating in this study.
Confidentiality: All of your answers will be kept confidential. Your name and any other personal information about you will never appear in any reports or publications about this study. Your answers will only be used for research purposes only.
Voluntary Participation
Participation in this research is completely voluntary and it is your right to not participate in this study.  You may end your participation at any time for any reason, and you may choose not to answer any question, this will not affect your relationship with your leaders at any level of organization nor the researcher.
Questions
If you have any questions or correspondence about the research, you may email us at mdchartine@gmail.com or at ndagijimanajeanpierre01@gmail.com and you may call us at 0785172368 Chartine MD and on 0783957625 Pierre NJ.
Consent
I………...............Consent /accept to participate in this research project entitled: “Factors affecting nurses/midwives’ triage decision making and triage accuracy in emergency and maternity department of Kibogora District Hospital conducted by students of Kibogora Polytechnic. I have been explained the study in detail and its purpose. I understand that the information I will provide will be kept confidential, it will be used only for the purpose of the current study. I also understand that I have the right to withdraw from this study at any time and ask for clarification if there is any difficult. My participation is voluntary and no force has been used and I will not encounter any risk as related to this project. No rewards or payment will be provided for participation.
Participants signature-------------------------    			Date -------------------------
Researcher’s signature ------------------------    			Date -------------------------

D. Kinyarwanda Version
Inshoza y’ikinyarwanda
Amazina yacu ni Ndagijimana Jean Pierre na Mukamugisha DieuMerci Chartine. Twiga mu mwaka wa gatanu mu ishami ry’igiforomo rusange, turi kwitegura guhabwa impamyabumenyi y’iciro cya kabiri cya kaminuza muri kaminuza ya kibogora polytechnic. turigukora ubushakashatsi ku bintu bifite uruhare ku baforomo n’ababyaza bakorera muri serivisi y’indembe na “maternity” mugufatwa kw’icyemezo kijyanye na “triage” ndetse na “triage” y’ukuri mu bitaro bya kibogora. Tubashimiye kubwo kwemera gufatanya natwe muri ubu bushakashatsi. umusanzu wanyu ni ingenzi cyane kdi uzadufasha.
Uko bikorwa
Iyo wemeye gufatanya natwe muri ubu bushakashatsi hari ibibazo usabwa gusubiza. Amakuru utanga agirwa ibanga kandi agakoreshwa muri ubu bushakashatsi gusa. Ntangaruka uzahura nazo muri ubu bushakashatsi kandi ntakiguzi gihabwa utanze amakuru. Ni ubushake bwawe kwemera kwifatanya natwe. Kandi ufite uburenganzira bwoguhagarika no kwanga gusubiza ibibazo ku mpamvu zawe bwite ntankurikizi.
Kwemera
Njyewe,                                                        Nemeye kwifatanya na Ndagijimana Jean Pierre na Mukamugisha DieuMerci Chartine muri ubu bushakashatsi bugamije gusuzuma ibintu bifite uruhare ku baforomo n’ababyaza bakorera muri serivisi y’indembe na “maternity” mugufatwa kw’icyemezo kijyanye na “triage” ndetse na “triage” y’ukuri nyuma yogusobanurirwa icyo ububushakashatsi bugamije.
Umukono w’ubazwa	                                                                                  Itariki
Umukono w’ubaza	                                                                         Itariki

E. ETHICAL APPROVAL

Plagiarism Checker X Originality Report
Similarity Found: 17%

Date: Tuesday, August 30, 2022
Statistics: 2441 words Plagiarized / 14711 Total words
Remarks: Low Plagiarism Detected - Your Document needs Optional Improvement.
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KIBOGORA POLYTECHNIC FACULTY OF HEALTH SCIENCE DEPARTMENT OF GENERAL NURSING A0 TOPIC: ASSESSMENT OF FACTORS AFFECTING NURSES/MIDWIVES TRIAGE DECISIONS MAKING AND TRIAGE ACCURACY IN EMERGENCY DEPARTMENTS OF KIBOGORA DISTRICT HOSPITAL Case study: Kibogora district hospital Period: 2022 A Research Paper submitted in partial fulfillment of the requirements for the Bachelor’s degree with honor in General Nursing PREPARED BY: MUKAMUGISHA Dieu Merci Chartine 1900392 NDAGIJIMANA Jean Pierre 1900435 _ _ _ SUPERVISOR: MUVANDIMWE Jean de la Croix (Assistant Lecturer) Kibogora, August 2022DECLARATION We MUKAMUGISHA Dieu Merci Chartine and NDAGIJIMNANA Jean Pierre hereby declare that this our own original work and not a duplication of any similar academic work. It has therefore not been submitted to any other institution of higher learning. All materials cited in this paper which are not our own have been duly acknowledged. MUKAMUGISHA Dieu Merci Chartine Signature………………….. NDAGIJIMANA Jean Pierre Signature………………….. Date:…………………………. Declaration by the Supervisor I declare that this work has been submitted for examination with my approval as KP Supervisor SUPERVISOR’S NAME: ………………….. SIGNED……………….. 

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