COVID-19 disease, also known as acute respiratory syndrome COVID-19, has recently become an epidemic worldwide. This infectious disease, caused by the novel coronavirus, was first identified in Wuhan, China, and reported for the first time in Iran on February 20^th, 2020 [1]. In pandemics and crises, the preparation of health care providers, especially emergency and critical care nurses, to manage increased infectious disease outcomes is essential [2-4].

Triage is a process of prioritizing patients based on the acuity of the problem in order to provide the optimal treatment in the shortest possible time, which is the basis of visits and other services in the emergency department [5, 6]. The word ‘triage’ is derived from the word ‘trier,’ which means to sort [7-9]. Depending on the circumstances, this concept is used in unexpected events, such as epidemics and crises and, in routine circumstances, hospital emergencies [9, 10]. The history of this system in hospitals dates back to the early 1960s in US hospitals [11-13]. Accurate information is lacking about the history of triage implementation in a current manner in Iran. However, it seems that with the development of emergency medicine in the country around 2000, the issue of in-hospital triage was accentuated, and the implementation guidelines and principles of setting up a hospital triage system in emergency departments were communicated to all hospitals by Iran’s Ministry of Health and Medical Education in the spring of 2011 [6]. Due to the overcrowding in the emergency department, there is a need to prioritize patients. This method, particularly in epidemics, is the most practical action in the emergency department to reduce the way patients are ignored and care for critically ill patients [9]. The ESI triage is a five-level triage method in which patients are categorized based on two criteria of disease acuity and resources required for the patient; the former is characterized by the presence or absence of life-threatening factors and organs, high-risk situations, and vital signs, the latter is determined based on the nurse’s experience and comparing the current patient with similar cases. In this method, the triage nurse first evaluates the patient based on the acuity of the disease and the patient’s condition. In less-acute cases, i.e., in the absence of life/organ-threatening conditions or high-risk situations (triage levels 1 and 2), the nurse categorizes the patient based on previous experiences of other patients and triage system training while estimating the resources needed for the patient in the emergency department. Therefore, the triage nurse, in addition to being fully informed about the algorithm, is required to have sufficient experience [14, 15].

However, to be implemented, this system requires a set of elements, including sufficient space, required resources and equipment, a communication system, and an accessible treatment area supported by an experienced professional team. In the meantime, it seems that the role of an individual implementing triage, i.e., the triage nurse, is of particular importance, and in the case of emerging epidemics, the way to deal with patients with confirmed and suspected diseases can be a potential factor in causing a disaster. As the accuracy, correctness, and correct time of decision-making by the triage nurse have a direct effect on the emergency department's performance, identifying opportunities and challenges for effective triage and promoting its quality in epidemics of emerging diseases is crucial [15].

Various studies indicate diverse complications in medical centers regarding effective triage, such as a lack of proper implementation strategies and activities related to training, maintaining change, motivation, creating consensus, and organizing information [16], lack of necessary training on triage for nurses and understanding their responsibilities in this unit [15], communication problems and lack of resources and equipment, as well as recruiting inexperienced staff in the triage unit and the lack of a triage nurse in the emergency department [9]. In studies conducted in Iran, challenges, such as low skills and speed of nurses during triage [17], have been mentioned. Furthermore, clinical incompetence and management inability in emergencies are recognized as challenges for Iranian triage nurses [18].

In the emergency department, to have a successful triage, especially in times of crisis, it is vital to benefit from a clear and appropriate practical pattern and operational instructions. In order to achieve optimal results, investigating the current problems and obstacles and gaining accurate insight to solve probable complications may help improve the performance and quality of triage in facilities and hospitals [9].

Given the complex nature of the challenges facing triage and the impact of epidemics on its implementation, there is an urgent need to recognize its dimensions in the group providing this process, namely nurses. Examining these perspectives and discovering the challenges of triage implementation during an outbreak of emerging coronavirus disease may be used as a practical guide to resolving the problems of the hospital triage system during epidemics and a reliable solution for managers to establish a hospital triage system in epidemics. On this path, nurses working in emergency departments are among groups whose information and experiences can be used to explain the challenges. This group of medical staff can be the foremost source of information due to their presence on hospital front lines. Nurses are able to provide information that, if properly evaluated, can improve the triage process. Therefore, considering the importance of triage and its impact on social, cultural, and organizational conditions and the lack of sufficient resources and research in this regard, as well as the existence of a research gap, the researcher aimed to explain the challenges and obstacles to triage during the COVID-19 pandemic from nurses’ perspective using content analysis method.

In the present study, the participants’ age ranged between 26 and 45 years, and their mean age was 35.5 years. In total, two men and 11 women with a bachelor’s degree (13 individuals) and a master’s degree (2 individuals) with an average work experience of 10 years (2-20 years) participated in the study. Analysis of the findings from the interviews led to the extraction of two main themes (alone in crisis and defective triage), four categories, and fourteen subcategories (Table 1).

Given the prominence of triage in crises, implementing standard triage and providing quality services in this area is of particular importance and vital. In order to achieve optimal results in triage, investigating the problems and obstacles may help to gain the correct insight and alleviate the challenges. Although several studies have been carried out on triage and the necessity to perform it in crises, few have discussed the challenges and obstacles to triage during the COVID-19 pandemic. The results of the present content analysis indicated that the main challenges and obstacles to triage during the COVID-19 pandemic appeared in two main themes: ‘defective triage’ and ‘alone in crisis.’ The ‘defective triage’ theme consisted of two categories: ‘inability to implement standard triage’ and ‘lack of efficient planning,’ and the theme ‘alone in crisis’ consisted of two categories: ‘triage personnel’s heavy workload’ and ‘insufficient support for triage personnel.’

Most nurses introduced the lack of efficient planning during the coronavirus disease crisis as a factor causing a challenge for the treatment team. Planning and preparing for the crisis during and prior to it is one of the fundamental pillars of effectively dealing with the crisis. According to the World Health Organization (WHO), preparedness is one of the practical factors in reducing the damage caused by crises [22]. In the present study alike, it was revealed that managers’ lack of awareness and insufficient attention to the crisis of emerging diseases as well as the establishment of triage units in temporary locations without proper planning and comprehensive view of the subsequent issues using systems that partially, not thoroughly, solve problems, had led to fundamental complications in the triage system during COVID-19 crisis. In this regard, Bijani (2019) pointed to the structural and functional challenges in triage from the nurses’ perspective as management challenges. The results of this study were consistent with the present study, which, in fact, refers to non-compliance with environmental, staffing, and equipment standards in the category of ‘inability to implement standard triage’ and ‘failure to separate wards,’ ‘officials’ absence during the crisis,’ and ‘failure to utilize experiences’ in the category of ‘lack of efficient planning,’ indicate the structural and managerial challenges [18]. Likewise, their study highlighted the importance of proper and rapid management of infectious diseases in triage to timely identify patients with infectious diseases and their immediate isolation and proper control of conditions to prevent transmission to other patients and those who were referred to medical centers, in an effective triage [23]. The theme ‘alone in crisis’ refers to the high workload of triage personnel and insufficient support for them. Most nurses had a negative view of crises; in fact, they felt alone in crises. Numerous nurses mentioned heavy workloads, high stress resulting from the countless deaths of patients and the loss of colleagues, dealing with their fears and fears of family troubles, colleagues abandoning work, and the absence of most managers during the crisis as the symbols of their loneliness. This is while, in the post-crisis phase, many people who refused to attend the hospital during the crisis returned to work. The remarkable thing is that we always see high traffic of nurses in the emergency room, but during the Corona crisis, this work pressure increased many times, which caused the nurses to feel more lonely than in normal conditions. In the results of the study by Bijani (2019), which are in line with the present study, nurses referred to job abandonment, fear, physical and psychological effects related to a high workload of triage personnel, lack of job security, lack of incentive system, improper communication and cooperation between nurses and physicians, weak interaction between nurses and managers, and inadequate support for the personnel as triage challenges [18]. All these issues become more accentuated and unbearable in times of crisis. Various factors may help nursing staff reduce this burden. Janssen et al., in their study on influential factors in triage in the emergency department, stated that various factors at the individual, social and organizational levels, such as motivation and commitment, physicians’ awareness, workload, access to resources, support of managers, and the cooperation of nurses and physicians are effective factors in triage. Consequently, more effective triage can be planned and implemented by developing appropriate strategies, raising awareness, paying attention to changes, and establishing motivation, consensus, and cooperation. In the above-mentioned study, nurses primarily pointed to the lack of resources and cooperation between groups and managers and physician shortages [16]. The results of this study are consistent with the present study results, which point to nurses’ high workload and insufficient support for them during triage as the challenges of most nurses in the triage unit, paying attention to which is of great importance to increase the triage quality.

Various studies in this field indicate several challenges in medical centers regarding effective triage. Deficiencies in the necessary nurse training on triage and elucidating their responsibilities in this unit [15], communication problems, lack of resources and equipment, recruiting inexperienced personnel in the triage unit, as well as the failure to allocate the nurse in charge of triage in the emergency department [9], were among the challenges introduced in these studies. In this regard, training proper triage and alleviating barriers to its effective implementation [24], as well as controlling environmental barriers, such as employees’ stressful working conditions, lack of resources, awareness/knowledge, empowering physicians about disease risk factors and increasing their skills in triaging specific diseases have been reported in these studies [25]. The results of these studies are in line with the present study results, which refer to the planning and implementation of standard triage and alleviation of barriers to the triage personnel’s action as effective factors for the implementation of a standard and non-challenging triage.

Triage is of particular importance during epidemics and biological crises. The results of this study point to the challenges of effective triage planning and implementation and the nursing staff’s loneliness during triage in the crisis from their perspective in the recent COVID-19 pandemic. Therefore, paying attention to these challenges, their control, and management during epidemics, as well as planning to prevent the occurrence of these problems, seems important and necessary.

M KH contributed to conceptualization, project administration, supervision, methodology, and original draft. M A participated in writing, reviewing, editing, formal analysis, and original draft: M JSN contributed to methodology, data curation, and validation. M A contributed to conceptualization, data curation, supervision, reviewing, and editing.