International Emergency Nursing (2009) 17, 226– 232

available at www.sciencedirect.com

journal homepage: www.elsevierhealth.com/journals/aaen

Working with Manchester triage – Job satisfaction

in nursing
Susanne Forsgren BSc (RN) a, Berit Forsman BSc (RN) a,
Eric D. Carlström PhD, MA, RN (Senior Lecturer) b,*

a
Department of Nursing, Health and Culture, University West, Trollhättan, Sweden
b
Health Management, Policy and Economics, Department of Nursing, Health and Culture, University West,
SE-461 86 Trollhättan, Sweden

Received 13 December 2008; received in revised form 22 March 2009; accepted 23 March 2009

KEYWORDS Abstract
Triage; Introduction: This article covers nurses’ job satisfaction during triage at emergency depart-
Job satisfaction;
ments in Western Sweden.
Nursing;
Methods: Data was collected from 74 triage nurses using a questionnaire containing 37 short
Sweden
form open questions. The answers were analyzed descriptively and by measuring the covari-
ance. The open questions were analyzed by content analysis.
Results: The results showed a high degree of job satisfaction (88%). Triage as a method, the
interesting nature of the work, and a certain freedom in connection with the triage tasks con-
tributed to job satisfaction (R2 = 0.40). The nurses found their work interesting and stimulating,
although some reported job dissatisfaction due to a heavy workload and lack of competence.
Most of the nurses thought that Manchester triage (MTS) was a clear and straightforward
method but in need of development.
Conclusions: The rational modelling structure by which the triage method is constructed is
unable to distinguish all the parameters that an experienced nurse takes into account. When
the model is allowed to take precedence over experience, it can be of hindrance and contribute
to certain estimates not corresponding with the patient’s needs. The participants requested
regular exercises solving and discussing patient scenarios. They also wanted to participate on
a regular basis in the development of the instrument.
ª 2009 Elsevier Ltd. All rights reserved.

Introduction

* Corresponding author. Tel.: +46 702738126; fax: +46 520223099. This study addresses triage nurses’ job satisfaction. More and
E-mail address: eric.carlstrom@hv.se (E.D. Carlström). more patients tend to seek care at emergency departments,

1755-599X/$ - see front matter ª 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ienj.2009.03.008
Working with Manchester triage – Job satisfaction in nursing
and it is of increasing importance to use methods that meet
the patient’s medical needs. It is important to treat patients
according to need, instead of according to order of arrival
(Palmqvist and Lindell, 2000; Göransson et al., 2005;
Olofsson et al., 2009). This places demands on the nurse’s
ability to make correct judgements.
Triage is the process that analyzes the care needs of ill
and injured patients. The judgement is based on the pa-
tient’s symptoms. It is done through a grading of the medi-
cal degree of urgency, and is often performed by a nurse.
When the patient arrives at the emergency department,
he explains his symptoms to a triage nurse. This explanation
forms the basis for the triage (Burr and Fry, 2002). An effi-
cient triage model is expected to increase the quality of
care, adjust the waiting time, and shorten the stay at the
emergency department for gravely ill patients (Grossman,
2003). Triage nurses are considered to have special skills.
They are expected to be skilled, intelligent, and empathetic
(Grossman, 2003). Cone and Murray (2002) suggest that tri-
age nurses should have at least one year’s emergency
department work experience and formal triage training to
be able to perform their tasks in a satisfactory manner. Ear-
lier studies have pointed out the fact that factors such as
good working conditions and competence are valuable for
triage (Ritchie et al., 2002; Considine and Hood, 2000;
Tak-Ying Shiu, 2007). There is, however, a lack of in-depth
studies on factors that contribute to job satisfaction for tri-
age nurses. The research ‘‘question’’ posed in this study is;
what contributes to job satisfaction during triage work?
Background
Modern triage at emergency departments has been
developed in Anglo-Saxon countries (Burr and Fry, 2002).
In Canada, the need for a triage system was voiced already
during the 1970s, but it did not become a reality until the
1990s when ‘‘The Canadian Emergency Department Triage’’
(CTAS) was introduced. CTAS is a scale solely based on vital
parameters (Murray et al., 2004). In Australia and New Zea-
land, the ‘‘Australian Triage Scale’’ (ATS) was introduced in
1994 and it encompasses both the vital functions and the
symptoms of the patient (Australian College for Emergency
Medicine, 2002). Currently, hospitals in the USA use various
triage methods. The most widely used is the ‘‘Emergency
Service Index’’ (ESI). In Sweden, three different triage
methods are used: ‘‘Adaptive Triage’’ (ADAPT), ‘‘Medical
Emergency Triage and Treatment System’’ (METTS), and
‘‘Manchester triage’’ (MTS). This study has been limited to
MTS, which is used at emergency departments in Western
Sweden.
Manchester Triage System
During 1989 a group of physicians and nurses from various
emergency departments in Manchester, Great Britain, initi-
ated the development of MTS. The goal was to work out a
common model that could be used at all the hospitals in
Manchester. The model has since become a national stan-
dard not only in Great Britain, but also in the Netherlands
and Portugal (Widfeldt and Örtenwall, 2005). The method
is described as a sensitive instrument that identifies gravely
227
ill patients in need of intensive care (Cooke and Jinks,
1999).
Reliability is considered to be of central importance for a
triage method, but perfect agreement amongst the partici-
pants is seldom reached. A study by Versloot and Liutde
(2007), however, showed good measured results using
MTS. At least 90% of the triage nurses assigned to the pa-
tients exactly the same triage categories. The correspond-
ing value for ESI (Gilboy et al., 2005) was 75%. The study
was, however, relatively limited. It was based on eight
experienced triage nurses’ estimates of a total of 400 simu-
lated patient cases. In a more extensive study, 79 triage
nurses from seven emergency departments in Western
Sweden performed a total of 1027 estimates using MTS
(Olofsson et al., 2009). The correlation between the nurses’
estimates was 73%. The most urgent categories had the
highest correlation (92% and 91%, respectively), whereas
the lower priority levels had a lower correlation (66% and
63%, respectively). The authors of the study suggested that
MTS fails as decision-making support, particularly for the
group of patients in need of less urgent care (Olofsson
et al., 2009).
The first step in MTS is where the person responsible for
triage chooses a flow chart based on the patient’s reason for
contacting the emergency department (Mackway-Jones
et al., 1997). Every flow chart begins by identifying possible
criteria indicating life-threatening conditions for the pa-
tient, such as affected breathing, blood pressure or pulse.
If none of these conditions exist, the nurse continues along
the flow chart until criteria are found that match the state
of the patient. MTS has a five-level scale. The highest level
means that a gravely ill patient with a life-threatening con-
dition is given immediate care. Such patients are assigned
category red. Urgent conditions are assigned category or-
ange and are considered able to wait for ten minutes. Less
urgent patients are assigned category yellow and can wait
up to 2 h. Non-urgent patients are assigned category green
and can expect a waiting time of up to 2 h. Other patients
are given a blue triage level. This means that they can wait
4 h. They can also be advised to visit a primary care medical
clinic (Mackway-Jones et al., 1997).
An under-triage can risk the patient’s health and an over-
triage means that the patient gets a higher priority than is
necessary. Furthermore, an over-triage can mean that the
emergency department’s resources are not optimized. An
ideal system should be able to quickly sort and identify pa-
tients in need of immediate care. This means that the scale
and the estimation levels must be absolutely clear (Travers
et al., 2002; Fernandes et al., 2005).
Job satisfaction
Job satisfaction is here considered to be where a task is
experienced as stimulating. The opposite, i.e. low or no
job satisfaction implies a lack of stimulation. A lack of stim-
ulation makes the work situation unsatisfying. Stimulating
tasks are here considered to consist of interaction in a so-
cially valued decision-making process (Antonovsky, 1987;
Mullins, 2002).
This definition, however, is over-simplified. Job satisfac-
tion is a multi-faceted term and its meaning can vary from
228
individual to individual (Mullins, 2002). Important variables
stem partly from the internal (in this case the triage nurse)
and are partly external (corresponding to the emergency
department where the nurse works).
Variables that stem from the internal can be their ability
in taking initiative or to make decisions, their attitude to-
ward work, interest, training and ability to control the work
situation (Karasek and Theorell, 1990; Spector, 1997; Kauff-
man and Kauffman; 1998). Such skills are often assimilated
under the term competence. Competence thus includes a
combination of knowledge, abilities and personal skills
(Sandberg and Targama, 1998).
Additional external factors that are important for job
satisfaction have proven to be as follows: how much respon-
sibility the work demands, what support is available from
colleagues and supervisors, and the nature of the work
and organization (Karasek and Theorell, 1990; Spector,
1997; Kauffman and Kauffman, 1998; Brown, 2002).
Clinical competence
McGrath et al. (2003) claim that the nursing profession is
characterized by a heavy workload and that it is associated
with great responsibility. There are studies that show that
despite complex triage tasks, the clinical competence of
the nurse can be improved by theoretical and practical
training (Considine and Hood, 2000; Hamilton, 2004;
Stuhlmiller et al., 2004; Atack et al., 2005). Regular training
in the art of triage has proven to increase the ability to han-
dle stressful work situations. Regular training develops the
triage nurses’ ability to identify with the patient’s degree
of urgency, assign the patient a diagnosis and a location,
and coordinate personnel resources (Ritchie et al., 2002;
Considine et al., 2004; Chung, 2005; Fry and Stainton,
2005; Göransson et al., 2005). In a study of 222 Australian
nurses, the ability to perform triage was shown to be depen-
dent on the nurses’ training. The study highlighted knowl-
edge of the patient’s vital functions, urgent care,
communication, and informational strategies as important
for triage (Considine and Hood, 2000).
None of these studies, however, have pointed to how such
factors have influenced job satisfaction. The demands on the
triage nurse are high. She is expected to rapidly be able to
register symptoms that can lead to permanent bodily injury
or death. A delayed decision-making process or an incorrect
decision can lead to serious consequences for the patient
(Cole and Kleinpell, 2006). Tippins (2005) describes the
uncertainty among triage nurses due to a lack of knowledge
and experience. They did not trust the measured data and
this delayed the patient care. The difficulty in determining
vital parameters has primarily shown itself during triage of
exposed groups like small children, elderly, and patients
with communication difficulties (Cooper et al., 2002).
Another complicating factor has proven to be a lack of
socio-cultural knowledge in order to assess people from dif-
ferent cultures and children of varying ages (Hjelm, 2005).
To sort and prioritize everyday healthcare issues puts the
nurse’s socio-cultural ability to the test. Under such circum-
stances, it has proven to be a challenge to extract relevant
information from the patient’s story (Grossman, 2003;
Hjelm, 2005).
S. Forsgren et al.
Method
To answer the research question, surveys were sent out dur-
ing the autumn of 2007 to 102 triage nurses at four emer-
gency departments in Western Sweden. The supervisor at
each respective emergency department gave access to the
research area. The nurses all had at least six months of
MTS experience and the survey response was 73%.
The survey
The survey was analyzed in a quantitative as well as a qual-
itative way. The instrument contained 37 questions primar-
ily with five alternative answers of the Likert type. The
survey was validated through a pilot study where five nurses
tested the questions. This led to a small adjustment to clar-
ify some of the question structuring (Trost, 2001). The
instrument was tested through a calculation of Cronbach’s
alpha. The results varied between 0.68 and 0.84 which,
according to Brace et al. (2006), is considered to be satis-
factory. McKinley et al. (1997) also used a questionnaire
to measure patient satisfaction and found values of Cron-
bach’s alpha ranging from 0.61 and concluded that the ques-
tionnaire had satisfactory reliability.
The surveys were numbered and variables were defined
in the computer program ‘‘Statistical Package for the Social
Sciences 14.0’’ (SPSS) (Brace et al., 2006). Statistical signif-
icance was established at p < 0.05. The quantitative part of
the analysis stems primarily from descriptive data and
regressions. The study included two open questions that
were answered by 46% of the participants. The answers
were processed with the aid of content analysis. The quali-
tative analysis meant that the obvious part of the answers
was extracted from each respective question (Graneheim
and Lundman, 2003).
Results
The triage nurses’ ages were relatively evenly distributed
between ages 25 and 64. Three of the nurses were under
25. As many as 37% of the nurses participating in the study
had less than five years’ work experience which meant that
a large percentage was relatively newly trained. Within the
study group, 70% had more than one year of MTS experi-
ence. When the study was performed, 51% considered MTS
to lead to shorter waiting time and processing time. By con-
trast, as large a percentage as 20% claimed that MTS rarely
or never leads to shorter waiting time and processing time.
Sixty-two percent of the triage nurses had participated in
one-day MTS training. More than half of the nurses had par-
ticipated in a two-day trauma training and as many as 30%
had university education in emergency healthcare. Several
nurses had also increased their competence in coronary
healthcare. When asked if their employers had offered them
any continued triage training during the past six months,
20% answered ‘‘yes’’. The competence development in-
cluded semi-annual discussions using various patient cases
and triage situations. No less than 23% of the triage nurses
stated good judgement and a ‘‘clinical look’’ to be the most
important aspects of competence in triage. The majority
Working with Manchester triage – Job satisfaction in nursing
(61%) believed that they would need to achieve greater
competence through training. Of these, 46% felt that they
specifically had need for more training on simulated patient
cases.
Open questions
Two open questions prompted the participants to describe
two triage scenarios. One of these related to a high level
of job satisfaction. The other one was based on an unsatis-
factory situation, which meant low or no job satisfaction.
From the content analysis, the following core categories
were extracted: the MTS method, the work environment
at the emergency department, and the individual compe-
tence. The results thus consisted of internal and external
factors.
The open questions revealed that older colleagues at
times questioned the triage decisions of the younger ones.
Difficulties in decision-making were encountered primarily
during the assessment of patients with multiple diseases.
Since this patient group had increased in number, greater
requirements were placed on the nurses’ competence. This
could lead to mistakes, as illustrated by the following
comment:
‘‘Untrained but self-assured nurses will make inaccurate
triage’’
A competent nurse could, on the other hand, act inde-
pendently and with success. This could, for example, be
through using painkillers or test sampling in order to later
give a patient lower priority. Meanwhile, patients with high-
er priority could be treated. One of the nurses made the fol-
lowing comment:
‘‘Competence gives nurses a sense of security’’
This nurse values competence as an important factor in
order to achieve satisfaction. Competence provides free-
dom to act independently and reduced insecurity.
Job satisfaction
In order to gain an understanding of the job satisfaction, the
researchers posed questions based on the definition of the
term, i.e. whether or not the triage was experienced as
stimulating. The job satisfaction was high. Strikingly many
found the work frequently stimulating (88%). A large major-
ity also believed that the task was interesting (98%). The
majority of the triage nurses also felt that they had freedom
in taking initiative (57%) and making their own decisions
(51%) within their triage function. This freedom contributed
to the job satisfaction.
As many as 70% believed that a triage nurse needs to pos-
sess certain unique attributes, such as assessment compe-
tence and communication skills, and as many as 23% were
of the opinion that some colleagues have limited ability to
work with MTS.
The participants had the opportunity to give examples of
factors that generated job satisfaction when working with
MTS. Twenty-seven percent stated that it was of utmost
importance to have a lot of experience working as a nurse.
Nine of the respondents admitted that their own compe-
229
tence was inadequate and that they had need for further
training.
Fifty-eight percent of the participants thought that they
had a good work environment. No less than 30 (40%) of the
nurses, however, felt that their work environment had seri-
ous faults. The question was posed in such a way as to bring
out reasons. The most frequent reason for faults in the work
environment was an excessive workload (given by 11
nurses). Only 35% of the participants felt that they had suf-
ficient time to analyze their own triage. There could quickly
be too many very urgent (orange) and urgent (yellow) pa-
tients waiting for care because of insufficient resources at
the emergency department. These patients’ conditions
could quickly worsen, which led to unsatisfactory work con-
ditions. Furthermore, it could occur that the nurse had to
leave her triage function and make herself available at an-
other section (73%). A quarter of the participants felt that
the workload was so great that it led to physical problems
such as headache, backache and joint problems.
A smaller percentage of the nurses (10%) considered the
lack of support in the organization to lead to decreased job
satisfaction. Although cooperation within emergency
department was satisfactory (87%), the majority (85%) con-
sidered triage to be the responsibility of a single nurse, the
triage nurses often made their own independent decisions.
However, the open questions prompted requests for triage
teams consisting of two nurses or a nurse and a physician.
Another reason for lack of job satisfaction was the MTS
method itself. Of the participants, 63% felt that MTS,
although clear and straightforward, was associated with
some difficulties. Ten nurses, all with considerable work
experience, described in the open questions how the meth-
od was not fully developed. No fewer than 54% considered
the method to be in need of development. They mentioned
that they could not always find key words or a suitable flow
diagram that could support their decision. This is illustrated
in the following comment:
‘‘It is a rigid system; sometimes it is difficult to identify
the patient’s reason to contact the emergency
department’’
Internal and external factors
The relationship between both internal and external factors
and job satisfaction was tested in a number of bivariate and
multiple regressions.
The strongest correlation was found for internal factors.
The view that the triage work was interesting largely con-
tributed to job satisfaction (R2 = 0.23). The same was true
for the ability to take initiative (R2 = 0.18). A skilled triage
nurse could perform certain tests on her own with the pur-
pose of changing the order of the waiting line into the emer-
gency department. The ability to make individual decisions,
however, showed a somewhat weaker correlation with job
satisfaction (R2 = 0.08).
That others in the organization had an understanding for
the nurse’s work task stands out as the most important
external factor for job satisfaction (R2 = 0.11). Such organi-
zational understanding suggested that the task was consid-
ered urgent and that the triage nurse’s role was seen as
230 S. Forsgren et al.

Table 1 Bivariate regression.

Dependent variable, job satisfaction n = 74
Independent variables: Pearsons R R-square F-value T-value Sign. Sign.95%
Internal factors:
A. Ability to make decisions 0.29 0.08 6.58 2.57 0.01 Sign
B. Ability to take initiative 0.43 0.18 15.99 4.00 0.00 Sign
C. Perception of that the work is interesting 0.48 0.23 21.07 4.59 0.00 Sign

External factors:
D. Sufficient time in the triage situation 0.13 0.02 0.27 1.13 0.26 Not sign
E. Sufficient time for analysis 0.16 0.02 0.02 0.14 0.89 Not sign
F. Support gained for the task 0.33 0.11 8.24 2.87 0.01 Sign
G. Good cooperation at the emerg. dept. 0.24 0.06 4.44 2.11 0.04 Sign
H. MTS is perceived as a clear method 0.32 0.10 8.05 2.84 0.01 Sign

Table 2 Multiple regression.

Dependent variable, work contentment n = 74
Independent variables: R-square 0402
Biv. regr. Mult. regr. Difference T-value Sign.
Stand. Beta Stand. Beta
A. Ability to make decisions 0.19 0.70 0.51 0.59 0.56
B. Ability to take intiative 0.28 0.73 0.45 2.39 0.02
C. Perception that the work is interesting 0.92 0.19 0.73 3.94 0.00
F. Support gained for the task 0.14 0.05 0.09 0.84 0.40
G. Good cooperation at the emerg. dept. 0.18 0.08 0.10 0.20 0.84
H. MTS is perceived as a clear method 0.10 0.03 0.07 2.30 0.03

important. In addition, MTS was perceived as a clear,
straightforward method (R2 = 0.10). Good cooperation at
the emergency department further contributed to job satis-
faction (R2 = 0.06) (see Table 1).
In a multiple regression, it was seen that internal and
external significant factors together explained 40%
(R2 = 0.402) of the job satisfaction. It meant that 60% were
still unaccounted for. Three variables were still significant,
the opportunity to take initiative, the perception that the
work is interesting, and the perception of MTS as a clear
straightforward method. The remaining variables displayed
low t-values and were lacking significance of their own.
The reason could be that they co-variate or that they were
present as an earlier link in connection with the cause. The
result indicates that MTS as a method, the interesting nat-
ure of the work, and a certain freedom in connection with
the triage tasks contribute to job satisfaction (see Table 2).
Discussion and conclusion
The goal of the study was to discover what contributes to
job satisfaction during triage work. The nurses in the study
were generally content with the triage work at the emer-
gency department. It was considered stimulating. There
was, however, limited ability to take initiative and to make
decisions. A third of the nurses mentioned that they had a
bad work environment and that their own competence
was insufficient. This result is supported by Grossman
(2003) and by Kauffman and Kauffman (1998) who claim that
job satisfaction depends on the competence, the support
from colleagues, the nature of the work, and the organiza-
tional structure. It is also supported by McGrath et al. (2003)
who emphasize that it is not primarily the emotional needs
or the direct contact with the patient that is a stress factor,
but rather the insufficient time to perform the tasks.
The triage nurses in the study generally speaking had
good formal training. Despite being regularly offered train-
ing, they requested more exercises utilizing patient cases.
They wanted more opportunities to discuss and analyze tri-
age with colleagues. This corresponds with Tippins (2005)
who emphasizes that there is a great need for more practi-
cal exercises involving patient cases, and less theoretical
training. Her view is that these exercises enable the identi-
fication of seriously ill patients.
This study revealed that experience was of importance
for the triage nurse. This contradicts Göransson et al.
(2006) who did not indicate any significant difference be-
tween greater and lesser experience during triage. One rea-
son for this could have been that the study by Göransson
et al. (2006) included nurses that did not use or were not
trained in an integrated triage method. The MTS method,
however, does not seem to exclude the need for
experience.
There appeared, however, a conflict between experience
and the MTS method. The experienced triage nurses in
Working with Manchester triage – Job satisfaction in nursing
particular felt that the method needed development. The
method was perceived as ‘‘rigid’’. This is supported by Olo-
fsson et al. (2009) who highlight difficulties in assessing
according to MTS, especially for less urgent patient catego-
ries. This could imply that the rational modelling structure
by which the triage method is constructed is unable to dis-
tinguish all the parameters that an experienced nurse takes
into account. When the model is allowed to take prece-
dence over experience, it can be of hindrance and contrib-
ute to certain estimates not corresponding with the
patient’s needs. This was reflected in that as many as a third
of the participants did not feel that MTS was safe for pa-
tients. Such factors reduced job satisfaction. This is sup-
ported by Kauffman and Kauffman (1998) who believe that
a discrepancy between the desired target and the actual re-
sult affects job satisfaction in a negative way.
Despite this, MTS contributed to making the nurses’ work
responsibilities at the emergency department understand-
able and easy to handle. There was a positive attitude to-
wards the triage implementation. The nurses felt that MTS
in itself simplified the meeting with the patient at arrival.
At the emergency department studied, MTS was imple-
mented as late as 2006, which means that the method has
been used for only a relatively short period of time. The re-
sult might be different if the study were repeated after a
number of years when the method had been developed.
MTS as a method, however, has limitations and needs to
be developed. One conclusion is that MTS can be too diffi-
cult for the inexperienced, a decision support for the rela-
tively experienced, and a hindrance for the very
experienced. The method can thus contribute to a smooth
work environment with high precision for certain groups of
nurses. There are therefore good reasons to further re-
search the influence of MTS in triage work.
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