KNOWLEDGE AND PRACTICE OF COLOR-CODED TRIAGE AMONG NURSES IN EMERGENCY UNITS OF SELECTED HOSPITALS IN LAGOS, NIGERIA.

TOPIC IS SUITABLE FOR:
1- Department of Nursing Science
2- Department of Emergency Nursing
3- Department of Public Health
4- Department of Medical-Surgical Nursing

TOPIC: KNOWLEDGE AND PRACTICE OF COLOR-CODED TRIAGE AMONG NURSES IN EMERGENCY UNITS OF SELECTED HOSPITALS IN LAGOS, NIGERIA.

TABLE OF CONTENTS
Title Page
Certification
Dedication
Acknowledgements
Abstract
CHAPTER ONE: INTRODUCTION
1.1 Background of the Study
1.2 Statement of the Problem
1.3 Objectives of the Study
1.4 Research Questions
1.5 Research Hypotheses
1.6 Significance of the Study
1.7 Scope of the Study
1.8 Definition of Terms
CHAPTER TWO: REVIEW OF RELATED LITERATURE
2.1 Introduction
2.2 Conceptual Review
2.3 Theoretical Framework
2.4 Empirical Review
CHAPTER THREE: RESEARCH METHODOLOGY
3.1 Introduction
3.2 Research Design
3.3 Research Setting
3.4 Population of the Study
3.5 Sample Size Determination
3.6 Sampling Technique
3.7 Instrumentation
3.9 Psychometric Properties of the Instrument
3.8.1 Validity of Instrument
3.8.2 Reliability of Instrument
3.9 Pilot Study
3.10 Method of Data Collection
3.11 Method of Data Analysis
3.12 Ethical Consideration
CHAPTER FOUR: ANALYSIS AND PRESENTATION OF RESULTS
4.1 Data Presentation
4.2 Demographic Analysis
4.3 Analysis of the Level of Knowledge of Colour-Coded Triage Among Nurses
4.4 Analysis of the Level of Practice of Colour-Coded Triage Among Nurses
4.5 Analysis of the Relationship Between Nurses' Knowledge and Practice of Colour-Coded Triage
4.6 Analysis of the Factors Influencing the Practice of Colour-Coded Triage Among Nurses
4.7 Test of Hypothesis
CHAPTER FIVE: DISCUSSION OF FINDINGS
5.1 Discussion of Findings
5.1.1 Level of Knowledge of Colour-Coded Triage Among Nurses
5.1.2 Level of Practice of Colour-Coded Triage Among Nurses
5.1.3 Relationship Between Nurses' Knowledge and Practice of Colour-Coded Triage
5.1.4 Factors Influencing the Practice of Colour-Coded Triage Among Nurses
5.2 Summary of the Study
5.3 Conclusion
5.4 Recommendation
5.5 Limitations of the Study
5.6 Implication of the Study to Nursing Practice
References
Appendix

ABSTRACT
This study was carried out to assess the knowledge and practice of colour-coded triage among nurses in the emergency unit of selected hospitals in Lagos, Nigeria, using the Lagos State University Teaching Hospital (LASUTH) and the Lagos University Teaching Hospital (LUTH) as a case study. The study was specifically carried out to assess the level of knowledge of colour-coded triage among nurses in the emergency units of the selected hospitals, determine the level of practice of colour-coded triage among the nurses, determine the relationship between nurses' knowledge and their practice of colour-coded triage, and identify the factors influencing the practice of colour-coded triage among the nurses. The study employed the descriptive survey research design. The study population comprised 215 registered emergency nurses of the Lagos State University Teaching Hospital and the Lagos University Teaching Hospital, while a total of 140 respondents were selected as sample size using the Taro Yamane formula. Out of the 140 questionnaires distributed, 131 were returned and 126 were validated for analysis. The questionnaire was used for data collection, while the data collected were analyzed using frequency tables, mean scores, and chi-square test of independence with the aid of SPSS version 27. From the responses obtained and analyzed, the findings revealed that nurses' knowledge of colour-coded triage was high at a grand mean of 3.71, while the level of practice of colour-coded triage was equally high at a grand mean of 3.56. The study also showed that there is a significant relationship between nurses' knowledge and their practice of colour-coded triage at χ² = 29.35, df = 1, P = .000. Likewise, the study found that factors such as inadequate staffing, high patient volume, and lack of standardized tools significantly influence the practice of colour-coded triage at a grand mean of 3.78. The study concluded that nurses' knowledge and practice of colour-coded triage were both high, and that a significant relationship exists between the two, though systemic and organizational factors continue to shape the consistency of practice. The study therefore recommends that hospital management should institute regular structured training on triage protocols, provide adequate standardized triage tools, address staffing shortages, and strengthen supervision to ensure consistent adherence to colour-coded triage practice.
Keywords: Colour-Coded Triage, Knowledge, Practice, Emergency Nurses, Lagos.

CHAPTER ONE
INTRODUCTION (Preview)
1.1 Background of the Study
Triage is an integral part of emergency nursing practice as it offers a structured framework to quickly evaluate patients and prioritize their treatment based on the severity of their needs. Internationally, current emergency care systems are based on a formal triage mechanism to help identify which patients need immediate care and which can be treated in a safe way after all more urgent patients have been cared for. In these systems, color coded triage is a useful way to convey the level of urgency assessed by using easily identifiable categories. According to AlShatarat et al. (2022), triage knowledge and practice is a process of making decisions and judgements based on the skills of nurses to evaluate the status of the presenting individual, determine the level of urgency and prioritize or classify the individuals into a triage level. In a similar vein, Gorick et al. (2023) explain that emergency triage is a complicated evaluation carried out at the starting presentation of patients and necessitates the determination of acuity, alongside the interpretation of clinical information, by the nurse. Color coding in this respect is a representation of the clinical evaluation result in a visual form that is easily understood and can help to prioritise treatment in an emergency. Eisa et al. (2020) also link good triage performance with the knowledge and use of the appropriate principles of assessment by the nurses. So, colour-coded triage is best interpreted not just as a colour assigned, but as the actual implementation of systematic assessment and prioritisation in emergency situations.
Building on the importance of triage assessment, nurses’ knowledge constitutes a major variable in understanding how effectively color-coded triage can be applied in emergency units. Knowledge, in this context, refers to the knowledge of the triage principles, clinical urgency, understanding of the triage categories, interpretation of patient signs and symptoms and awareness of the appropriate response associated with different levels of acuity. Al-Murshedi (2024) revealed that nurses' knowledge of triage is directly related to their knowledge about the assessment principles and the way patients are classified based on urgency. Elgazzar (2021) also studied the knowledge of the triage among emergency department nurses and knowledge was found to be one of the important dimensions for competent triage practice. Bahre et al. (2024) also reviewed the triage knowledge and perceived skills of nurses in adult emergency departments, highlighting the importance of nurses' knowledge for implementing triage processes. Moreover, Asiedu et al., (2025) show how knowledge is relevant to emergency nursing activities through a reflection of the understanding of triage and resuscitation by nurses. Therefore, knowledge of colour coded triage is not simply a recall of colour categories, but involves clinical reasoning to link patient assessment with urgency category. Knowledge is therefore an important basis on which to explore the practice of color-coded triage used by nurses.
Closely related to knowledge is the practice of colour coded triage, which refers to the nurses' knowledge of the principles of triage and how this is translated into actual clinical work in emergency units. Practice involves the systematic evaluation of patients upon arrival, gathering of relevant clinical data and interpretation, assessment of urgency, allocation of an appropriate triage category and communication of the triage category to enable emergency management. Malak (2022) studied knowledge, skills, and practices of emergency nurses, and found that competence in triage requires combining theoretical knowledge with practical skills. Similarly, Smith and colleagues (2022) looked at the accuracy of nurse led triage of adult patients and emphasized the importance of nurses using triage assessment to determine patient acuity. Chanif et al. (2023) also found a correlation between the knowledge of nurses and interpretation accuracy of the triage level, which further supports the notion that practice is an applied aspect of triage competence. In the same way, Rahmawati et al. (2023) studied the relationship between the implementation of triage and the role of emergency nurses and concluded that the practice of triage was an inseparable part of the role of emergency nurses. Assessment of practice, therefore, offers a chance to find out how nurses put into practice the theory of color coded classification while making routine assessments of patients.
Moreover, the correlation between nurse's knowledge and practice has been a subject of much attention in nursing and emergency-care related research because of the need for effective triage to involve both cognitive understanding and appropriate clinical application. Knowledge can be the foundation for becoming aware of the need for action, but practice can show how often this knowledge is integrated into patient assessment and classification. Bahlibi et al. (2022) found that the knowledge application and practice improvement dimensions of knowledge-based competency were relevant to a training on triage; indicating that learning and clinical application are related dimensions of triage competency. Similarly, when examining triage training with Emergency Severity Index and Australian Triage Scale, Pontisidis et al. (2024) discussed the impact of structured training on nurses' understanding and utilization of triage systems. Reddimalla et al. (2025) also investigated how a triage algorithm influenced nurses' knowledge and practices, providing further evidence of the link between nurses' knowledge and their triage practice. But, knowledge is not the only answer to determine triage practice. Olofinbiyi and Makhado (2024) explored nurses' perceptions of factors that impact the functioning of triage systems and Turen (2025) focused on decision-making and affective factors, among nurses working in emergency contexts. The above perspectives suggest that the learning of color-coded triage should take into account not only nurses' knowledge but also their practice and the factors that influence how this is implemented in the clinical environment.
Against this background, the Nigerian emergency-care environment provides an important context for examining how nurses understand and apply color-coded triage within routine hospital practice. Data from African contexts has shown that the competence of triage is still a vital field of emergency nursing research, as researchers have investigated the knowledge, hands-on skills, decision making, and experiences of triage of nurses in various health care settings. For example, Phukubye et al. (2021) investigated how triage knowledge and skills of Emergency Department nurses in rural South Africa could be improved, and Eyeson et al. (2026) investigated the lived experience of Emergency Department nurses with the South African Triage Scale (SA TS) in emergency care in Ghana. In Nigeria, Chinemerem (2023) explored the factors affecting triage decision-making by healthcare providers in hospital settings, highlighting its relevance as a critical aspect of emergency service provision in the context of Nigeria. This is also echoed in other studies such as Kouro and Iroko's (2024) study on the knowledge, practice, and perceptions of triage by emergency department personnel. These studies, together, define triage as a multi-dimensional nursing activity, which includes knowledge, clinical judgement, classification, and application. Therefore, the present study was specifically aimed at determining the level of nurses’ knowledge and practice of color coded Triage, the relationship between the two variables and the factors that affect its practice in the selected emergency units in Lagos and was titled “Knowledge and Practice of Color-Coded Triage among Nurses in Emergency Units of Selected Hospitals in Lagos, Nigeria”.
1.2 Statement of the Problem
Triage is a vital part of any emergency nurse's job as it allows them to quickly evaluate the patients they see and prioritize them based on the severity and urgency of their conditions. The main issue this study aims to explore is the necessity of adequate knowledge of colour coded triage amongst nurses and its implementation into their clinical practice. Ideally, emergency nurses should be able to identify the various clinical signs, determine the urgency of care, categorise by colour and use the triage system in a consistent manner. However, there is evidence from international research that there is measurable variation in triage accuracy. In the evidence-based review, Suamchaiyaphum et al. (2024) reported accuracy rates of triage from 59.3% to 82% in 14 studies and found that nurse, patient factors, and work environment factors were associated with accuracy. Afnan et al. (2021) also conducted a systematic review of 12,282 patients, and found that the sensitivity of the nurses prediction of eventual patient disposition at triage was 72% and the specificity was 83%. These findings demonstrate that nurses have an important role in the assessment and decision-making skills in emergency triage. Ideally, nurses should have the knowledge and always use a standardised method of triage, which allows patients to be prioritised according to clinical urgency. 
The situation in Africa further demonstrates the need to examine nurses' knowledge and practice of triage within specific healthcare contexts. African emergency departments have varying levels of nurse's knowledge, perceived competency and use of triage systems. In Nigeria, Iheonu et al. (2022) evaluated the triage knowledge score of 74 nurses in the emergency departments of three tertiary hospitals in Enugu State and revealed that 51.4% of the nurses had moderate triage knowledge scores. There were also differences between the participating hospitals in perceived patient-assessment, patient-categorisation and allocation skills, and weak relationships between the professional certification, emergency-department experience and triage skills and the practice of triage.  The use of triage classifications in South Africa also shows that good clinical judgement is necessary. The accuracy of nurse classification in Smith et al. (2022) study of an urban private hospital's adult emergency presentation found that not all nurse-led classifications matched with independently assessed classification. On a larger international scale, Suamchaiyaphum et al. (2024) also found that factors such as experience, training, patient characteristics and ED conditions were relevant to the accuracy of triage.  All the above indicate that knowledge and application of knowledge is a measurable aspect of competence in triage and should be studied in combination and not as proof of a triage system.
Within Nigeria, the available literature provides evidence that nurses' knowledge, skills, and use of structured triage approaches warrant further empirical investigation. This study revealed that over half of the nurses studied in Enugu State had moderate level of triage knowledge, with moderate, weak and non-existent relationships between the level of triage knowledge and the level of triage implementation practices, suggesting that knowledge may not fully explain the application of triage in clinical practice. Specifically, Onwochei et al. (2024) conducted a study on the implementation of ESI among nurses in selected hospitals in Lagos State, such as the National Orthopaedic Hospital, Lagos University Teaching Hospital, Lagos State University Teaching Hospital and General Hospital Gbagada which constitute evidence on the uptake of the ESI in Lagos State. Of 185 emergency-department (ED) nurses in their population, 139 were interviewed, and 130 of these questionnaires were analysed. Only 20 respondents (15.4%) reported that they used the Emergency Severity Index, and the other hospitals in the study reported using alternative methods to triage. The use and application of structured triage systems may differ between hospitals and nurses as shown in this Lagos-based evidence, although the Emergency Severity Index differs from colour-coded triage. In particular, the existing studies conducted in Nigeria have mostly focused on measuring the general knowledge of triage, the perceived skills, or on the use of specific triage instruments, and not necessarily the knowledge and practice of color coded triage in particular.
Given the implications of discrepancies in triage knowledge and practice, it is important to determine, in an empirical manner, how emergency patients are prioritised among the colour categories used by nurses. Good triage enables the correct prioritisation and prompt use of emergency-care resources while poor classification may impact the order in which patients are treated. Factors associated with triage accuracy included triage nurse characteristics, patient characteristics, and the emergency-department work environment (Suamchaiyaphum et al., 2024), and education, technology, and audit-and-feedback strategies were associated with short-term improvements in triage accuracy, knowledge, and skills (Ouellet et al., 2025). Previous studies have thus provided evidence on triage knowledge, perceived skills and accuracy, education, and structured triage instrument adoption (Iheonu et al., 2022; Onwochei et al., 2024; Suamchaiyaphum et al., 2024). However, there is a gap in the study in relation to the simultaneous appraisal of the knowledge and the actual practice of color-coded triage, the statistical association between knowledge and practice and factors affecting practice among the nurses working in the selected emergency units in Lagos. This gap will be filled with data more specifically related to the colour triage system, rather than the overall competence of triage or the adoption of the Emergency Severity Index. The present study thus aims to explore these dimensions in selected hospitals in Lagos, Nigeria with the theme “Knowledge and Practice of Color-Coded Triage among Nurses in Emergency Units of Selected Hospitals in Lagos, Nigeria”.
1.3 Objectives of the Study
The general objective of the study is to assess the knowledge and practice of color-coded triage among nurses in the emergency units of selected hospitals in Lagos, Nigeria.
The specific objectives of the study are to:
i.Assess the level of knowledge of color-coded triage among nurses in the emergency units of selected hospitals in Lagos, Nigeria.
ii.Determine the level of practice of color-coded triage among nurses in the emergency units of selected hospitals in Lagos, Nigeria.
iii.Examine the relationship between nurses’ knowledge and their practice of color-coded triage in the emergency units of selected hospitals in Lagos, Nigeria.
iv.Identify the factors influencing the practice of color-coded triage among nurses in the emergency units of selected hospitals in Lagos, Nigeria.
OTHER PARTS OF CHAPTER ONE INCLUDE:
1.4 Research Questions
1.5 Hypothesis
1.6 Significance of the Study 
1.7 Scope of the Study
1.8 Definition of Terms

CHAPTER TWO
REVIEW OF LITERATURE (Preview)
This chapter critically examines relevant literature that would assist in explaining the research problem and, furthermore, recognizes the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps. This chapter, therefore, focuses on the concept of triage, the concept of color-coded triage, knowledge of color-coded triage among nurses, practice of color-coded triage among nurses, relationship between nurses’ knowledge and practice of color-coded triage, factors influencing the practice of color-coded triage, etc. The chapter covers the following subheadings:

2.1 Conceptual Framework
2.2 Theoretical Framework
2.3 Empirical Review
2.4 Summary of Literature Review

CHAPTER THREE
METHODOLOGY (Preview)
Research Design: The study adopted descriptive research design.
Population of the Study: The target population for this study comprises all registered emergency room nurses, trauma care specialists, triage officers, and clinical nursing supervisors currently practicing within the Emergency Units (Accident and Emergency, Trauma, and Pediatric Emergency Departments) of selected tertiary healthcare institutions in Lagos State—specifically the Lagos State University Teaching Hospital (LASUTH), Ikeja, and the Lagos University Teaching Hospital (LUTH), Idi-Araba.
Sample Size Determination: The study adopted the Taro Yamane formula to determine a sample size of 140 participants
Sampling Technique: The sampling technique adopted for this study followed a multi-stage process designed to ensure that the 140 respondents drawn from the total population of 215 registered emergency nurses at LASUTH and LUTH were representative of the target population..
Research Instrument: The study utilized a structured questionnaire as the instrument for data collection.
Methods of Data Analysis: The collected data were analyzed using frequencies, percentages, means, and standard deviations to summarize and present the demographic characteristics of the respondents and their responses. Inferential statistics, such as Chi-square test of independence, were used to test the hypotheses.

CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION 
MAJOR FINDINGS (Preview)
The analysis results were presented in tables and charts. Based on the results obtained from the analysis, the following findings are made:
i. The study found that nurses in the emergency units of selected hospitals in Lagos, Nigeria, have a high level of knowledge of colour-coded triage, as evidenced by a grand mean of 3.71, which is above the acceptance benchmark of 3.00.

ii. The study found that nurses in the emergency units of selected hospitals in Lagos, Nigeria, demonstrate a high level of practice of colour-coded triage, as evidenced by a grand mean of 3.56, which is above the acceptance benchmark of 3.00.

iii. The study found that there is a significant relationship between nurses’ knowledge and their practice of colour-coded triage in the emergency units of selected hospitals in Lagos, Nigeria, as evidenced by a Pearson chi-square value of 29.35, degree of freedom of 1, and p-value of 0.000 (p < 0.05), leading to the rejection of the null hypothesis.

iv. The study found that several factors influence the practice of colour-coded triage among nurses in the emergency units of selected hospitals in Lagos, Nigeria, as evidenced by a grand mean of 3.78, which is above the acceptance benchmark of 3.00. The major factors identified include inadequate staffing, lack of standardized triage tools and equipment, high patient volume, insufficient training opportunities, poor supervision and monitoring, institutional policies and support, and workplace stress and burnout

CHAPTER FIVE: DISCUSSION OF FINDINGS
This chapter covers the following outline:.
5.1 Discussion of Findings
5.2 Summary of the Study
5.3 Conclusion
5.4 Recommendation
5.5 Limitations of the Study
5.6 Implication of the Study to Nursing Practice
References
Appendix

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