The Coronavirus Disease 2019 (COVID-19) pandemic has significantly impacted people worldwide [1] and has placed considerable strain on the medical system [2]. In the midst of this public health crisis, the Emergency Department (ED) plays a critical role as the hospital's frontline defense [3, 4]. Triage, a system implemented within the ED, is designed to evaluate patients quickly and effectively, ensuring that they receive prompt and efficient treatment [5]. This system is crucial for maintaining the safety and efficiency of treatment procedures in emergency departments [6]. In response to the COVID-19 outbreak, nearly all EDs established protocols for screening, testing, and managing patients with suspected COVID-19 infections [7], including in the triage process [8].

Throughout the world, triage is mainly done by nurses [9], who account for approximately 91.9% of triage performers in South Korea [10]. These triage nurses are the frontline medical staff who first assess patients arriving at the ED and establish the priority for treatment [11]. Amid the COVID-19 pandemic, triage nurses have taken on the role of gatekeepers, tasked with identifying potentially infected individuals through evaluation criteria [12]. Nevertheless, accurately categorizing all patients, including those with COVID-19, within a constrained timeframe has proven to be a formidable challenge [13]. The introduction of additional protocols and guidelines that require strict adherence has further increased their job stress [1, 14].

This gatekeeping role led to "triage fatigue" among nurses, stemming from inadequate medical resources, limited space, and fluctuations in patient flow, which in turn caused more stress than that experienced by other ED staff [15]. Job-related stress has a detrimental impact on nurses' occupational mental health [16]. Prolonged exposure to such stressors can harm individual health and impair cognitive decision-making processes, which may, in turn, affect patient outcomes [17]. The increased workload and pressure brought on by the pandemic have led to physical and psychological burnout among triage nurses, influencing their ability to classify patients effectively [9, 10].

Previous studies have primarily focused on the experiences and challenges faced by triage nurses, as well as the impact on their mental health during the initial stages of the COVID-19 pandemic [9, 18]. However, as the COVID-19 pandemic has now persisted for over three years, there is a pressing need for further research. This research should explore how the prolonged nature of the pandemic has altered the triage environment, identify the problems that have arisen in the triage process, and propose effective solutions. In Korea, there have been six distinct epidemic periods due to COVID-19. Notably, the fifth epidemic period (January 30 to June 25, 2022), which was characterized by the emergence of the Omicron variant, saw the highest number of confirmed cases, with a rate of 35,141.1 per 100,000 population [19]. Therefore, studies investigating the experiences of triage nurses during the peak and subsequent plateau of the COVID-19 pandemic, especially in the context of the spread of the Omicron variant, are needed. Such research can help to identify the evolving challenges faced by these healthcare professionals and provide reliable solutions for managing the ongoing situation.

Thus, this study aimed to gain a comprehensive understanding of emergency nurses' experiences with triage tasks during the COVID-19 pandemic, particularly between the peak and plateau phases over the past two years. It also sought to identify various issues associated with the evolving work environment.

In this study, 20 nurses who performed triage tasks in the ED participated (Table 1). Analysis of the emergency nurses' experiences with triage during the COVID-19 pandemic yielded four themes, 10 sub-themes, and 27 codes from 457 meaningful sentences. The four derived themes were "changes in priorities due to infectious diseases", "barriers to triage", "the emotional burden experienced by triage nurses", and "the journey toward growth" (Figure 1).

Figure 1
The experiences of emergency nurses performing COVID-19 triage.

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Table 1
General Characteristics of the Participants (N=20)

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This study comprehensively explored emergency nurses' experiences with triage work during the COVID-19 pandemic over the past two years. The data revealed four themes that encapsulate the physical and psychological challenges encountered during the triage process.

The first theme identified was "changes in priorities due to infectious diseases". Most participants agreed that infection screening became a priority in triage due to COVID-19, causing the basic triage process to be somewhat overshadowed. These shifts in triage priorities were inevitable and had both positive and negative impacts on patient safety. On one hand, the infection screening process was acknowledged as a critical component of triage to enhance patient safety. The Middle East Respiratory Syndrome (MERS) outbreak in Korea led to improvements in infection management, such as the establishment of a screening system [24]. However, once the MERS crisis subsided, medical staff's vigilance towards stringent infection control measures gradually diminished. Therefore, it is imperative to maintain ongoing preparedness for infection management, even after the current pandemic has been overcome, to ensure readiness for future infectious disease scenarios. On the other hand, the COVID-19 pandemic has led to the saturation of isolation beds and overcrowding in ED, with many patients experiencing deterioration while awaiting a bed [25]. The study also highlighted delays and restrictions in the timely treatment of emergency patients with high-severity conditions. Such medical delays pose significant risks to patient safety. It is essential to find a balance between meeting the urgent needs of patients and sustaining efforts to control the spread of infection. Consequently, there is a need to develop guidelines that prioritize treatment while also emphasizing infection prevention and control measures.

The second theme was "barriers that make the triage process difficult". These barriers emerged as participants grappled with increased workloads and insufficient nursing staff, unclear procedures and guidelines, and patients' indifferent attitudes. The increased workloads and shortage of nursing staff, which have been well-documented [26, 27], were exacerbated by the COVID-19 pandemic. This heavy workload led to physical and mental exhaustion, as well as task burnout among participants, which in turn impacted the quality and efficiency of triage [9]. To address this, the government should implement flexible staffing standards during a pandemic to ensure that medical institutions can adequately staff their nursing teams. In addition, following the outbreak of COVID-19, EDs in Korea quickly adapted their response to infectious diseases based on existing guidelines [28]. However, due to the unique characteristics of COVID-19, which differ from those of MERS [29], procedures were frequently revised, leading to confusion among the participants. The indifference of patients towards the triage process further complicates the situation for COVID-19 triage. When medical professionals have confidence in institutional protocols, it can help reduce stress levels and boost motivation [30]. Therefore, it is crucial for hospitals to develop multiple versions of a systematic infection response system that not only protects ED nurses by clarifying their roles but also secures patient cooperation.

The third theme was "the emotional burden that triage nurses undergo during triage". At the onset of the pandemic, through its peak and subsequent plateau, participants have consistently reported psychological distress stemming from concerns about infection, increased responsibilities, and emotional exhaustion. Echoing findings from previous studies [9, 18], the nurses in this study expressed worry about the possibility of contracting the disease themselves or transmitting it to their families due to their exposure to patients with COVID-19. They also faced significant pressure to prevent the spread of infection within the ED and coped with emotional exhaustion as a result of managing complaints from patients and their caregivers. The pandemic's challenging work conditions presented both direct and indirect risks to the participants' safety. Nurse managers must recognize these difficult work environments, proactively seek ways to improve them, and provide emotional support to triage nurses. During the peak and plateau phases of the COVID-19 pandemic, the influx of patients to the ED created challenges in promptly attending to those with urgent needs. Nurses experienced moral distress when they had to turn away emergency patients due to a lack of isolation space. Healthcare professionals, especially nurses, faced significant psychological and moral distress during the pandemic, with nurses being more vulnerable than other healthcare providers [31, 32]. Prioritizing the mental health of nurses is essential, as it impacts their own well-being, patient care outcomes, and the healthcare system's capacity to handle infectious diseases [26]. At a specialized coronavirus hospital in Korea, the Resilience through Individual and Systematic Empathy (RISE) program was established to strengthen the resilience of staff members [33]. This program successfully reduced employees' stress levels by continuously managing psychological well-being, offering targeted psychological support to high-risk individuals, and providing relaxation activities such as healing concerts and stress-relief meditation [33]. Similarly, hospitals in China implemented psychological evaluations and provided counseling services and training through psychological support programs, leading to a decrease in depression and anxiety among medical staff [34]. Therefore, it is critical for healthcare institutions to implement Employee Assistance Programs (EAPs) to help alleviate the buildup of negative emotions among nursing staff.

The fourth theme was "the journey for growth". Consistent with the findings of Sun et al. [35], our study showed that participants initially experienced negative emotions while grappling with numerous challenges during the early stages of the COVID-19 pandemic. However, as they persevered and developed coping strategies, these negative feelings gradually gave way to positive emotions, including a sense of progress and personal growth. Many nurses reported experiencing significant physical and mental stress in their response to COVID-19, yet they also acknowledged a concurrent sense of pride and accomplishment [36]. The personal growth of the participants has the potential to enhance their professional competence and self-esteem, which, in turn, can have a direct and positive impact on patient safety and health.

The generalizability of this study's findings to other regions and countries is limited, as it was conducted only among nurses working in South Korea. Nevertheless, the sample may be representative of triage nurses in Korea, despite the use of purposive and snowball sampling methods, because the participants were employed in hospitals located in metropolitan areas and had more than two years of career experience. The study is significant in that it has implications for COVID-19 triage work based on the perspectives and experiences of triage nurses during the pandemic.

From the onset of the pandemic to its peak and subsequent plateau, participants have faced ongoing physical and psychological issues stemming from the fear of infection, increased workloads, and emotional exhaustion. During the peak and plateau of the pandemic, the influx of patients to the ED created difficulties in providing timely care to those in urgent need. Despite encountering obstacles related to their work environment during the triage process, participants persevered in their efforts to differentiate between urgent and non-urgent patients and to safeguard the emergency department as the frontline defense against the pandemic. The peak and plateau periods of COVID-19 represented a period of professional growth for triage nurses. The insights gained from nurses' experiences during COVID-19 triage offer valuable lessons for managing and preparing for similar challenges in future infectious disease outbreaks. First, it is essential to develop integrated guidelines or protocols that can be adapted to changing situations to ensure the safety of critically ill patients. Second, the creation of operational manuals for patient triage during an infectious disease emergency is imperative. Third, the government should implement policies for staffing standards during a pandemic, enabling medical institutions to hire additional staff and ensure proper triage staffing levels. Fourth, nursing organizations should establish an Employee Assistance Program (EAP) to support the mental health and well-being of triage nurses during a pandemic. Based on the findings of this study, we propose further research to develop an enhanced strategy for future responses to infectious diseases by creating integrated triage guidelines and establishing a program to improve nurses' mental health.