The importance of the Emergency Department (ED) has grown in tandem with the rise in the number of ED users [1]. The ED plays a crucial role in classifying patients by severity and preventing overcrowding [1]. Moreover, the ED is instrumental in initially screening critically ill patients and effectively allocating appropriate medical resources and the flow within the ED. At present, ED nurses are responsible for performing triage in most EDs [2]. As the complexity and severity of patients visiting the ED increase, these nurses need triage competency to identify patients' clinical features early on and provide immediate intervention [2]. The Korean Triage and Acuity Scale (KTAS) was developed in 2012, coinciding with the emergence of triage in Korea. By January 2016, the KTAS was implemented in emergency medical centers nationwide for triage purposes [3]. The KTAS assesses patients who visit the ED based on process impression evaluation, infection confirmation, primary symptom selection, and primary or secondary considerations [3].

ED triage is a multifaceted decision-making process, influenced by individual competence and a variety of factors [2]—namely, patient-related, nurse-related, and environmental factors. Patient-related factors, as reported in the literature, encompass the primary complaint, underlying disease, vital signs, mode of transportation, physical appearance, pain level, and medical history, among others [4, 5, 6]. Nurse-related factors include experience, knowledge, beliefs, communication skills, and intuition [7, 8]. Environmental factors, on the other hand, involve ED overcrowding, human resources, and relationships with other hospital units [9].

Unlike patient-related factors, nurse-related and environmental factors can be improved; in particular, education can enhance nurse-related factors. Nurses are healthcare professionals who maintain direct and enduring relationships with patients. They have the crucial responsibility for accurately identifying clinically significant patient issues through patient communication and the establishment of mutual trust [10]. Factors such as self-leadership and communication skills have been identified as being related to nursing competency and nursing work outcomes [7, 8]. Bedside nurses often self-motivate by setting personal goals to improve their work performance or advance their skills [11]. Self-leadership, with its emphasis on self-management and intrinsic motivation, can equip nurses to proactively tackle problems and efficiently carry out tasks in emergency situations [8]. The communication skills of ED nurses significantly impact the effectiveness and accuracy of information exchange among healthcare providers. However, most research on self-leadership and communication has been primarily focused on their relationship with job performance or nursing work outcomes among general nurses [12, 13, 14]. Therefore, scarce evidence exists regarding the influence of self-leadership and communication on triage competency specifically among ED nurses.

Grit can also affect ED nurses' competence. Grit refers to consistent passion and effort toward a long-term goal. This implies continuously striving despite failure, adversity, frustration, and the plateau phenomenon in the process to achieve goals [15]. Importantly, people with high levels of grit demonstrate strong self-control. Therefore, these individuals can concentrate on imminent tasks and have a positive mindset. Consequently, they accept challenges and use them as learning opportunities, even if they fail [16].

Studies have examined the effect of ED nurses' critical thinking disposition on triage. However, to the best of our knowledge, no studies have considered self-leadership, communication skills, and grit, which are important factors for voluntarily and actively improving practical performance. Thus, this study aimed to identify the effect of ED nurses' self-leadership, communication skills, and grit on nurses' triage competency. Moreover, this study provides basic data for improving the quality of nursing at clinical sites.

This study examined the relationship between ED nurses' triage competency and their grit, self-leadership, and communication skills. Importantly, self-leadership, communication skills, and triage experience were identified as explanatory factors of triage competency. The final model (Model IV) of hierarchical regression analysis showed an explanatory power of 47.0%. Among the predictor variables, self-leadership was found to be the most significant variable for explaining triage competency in ED nurses.

Previous studies conducted in Korea have reported that self-leadership influenced nursing job performance and nursing work outcomes [12, 13]. A previous study [12] found that improving the nursing work environment increased self-leadership, which in turn enhanced nursing performance. Therefore, establishing management strategies that improve the nursing work environment and enhance self-leadership, which is characterized by positive self-perception, responsibility, and autonomy, is necessary to improve nurses' performance [12].

This study confirmed that self-leadership not only affected nursing performance, but also significantly contributed to triage competency in ED nurses. Self-leadership focuses on self-efficacy and intrinsic motivation, guiding and leading oneself in a rational direction and emphasizing autonomy and responsibility. A previous study conducted in Korea showed a positive correlation between nurses' self-leadership and autonomy, self-efficacy, relationality, and stability [14]. Therefore, it is suggested that ED nurses who possess self-leadership exhibit a high level of engagement in the task of patient triage, which contributes to the improvement of their triage competency. To enhance triage competency, it is necessary to create a nursing work environment in the clinical setting that allows nurses performing the essential task of patient triage to fully demonstrate their autonomy and expertise.

Triage places a registered nurse in a position to evaluate the urgency of treatment. This task requires the psychological and social management of nurses due to time pressure. Self-leadership has the potential to improve psychological and social management [8], and investigating whether triage in the ED is enhanced by self-leadership practices can be a good starting point for future research.

Considering the sub-categories of self-leadership, "self-criticism" (i.e., critiquing oneself when something goes wrong) scored the lowest at 2.52 points. A study [18] found that although mild guilt can be effective, excessive or habitual guilt can lower one's motivation to try [18]. Therefore, it is important for individuals to reflect on their shortcomings through appropriate self-criticism. Furthermore, it is essential for individuals to analyze the causes of failure and learn from them to avoid repetition. However, it is just as important to avoid being excessively critical. To demonstrate self-leadership that emphasizes one's potential and autonomy, the problems faced by young ED nurses with limited experience in the clinical field need to be effectively mitigated.

During the handover process in the ED, the effectiveness and accuracy of information exchange between paramedics and triage nurses are influenced by their proficiency in communication skills. Communication skills also play a role in determining whether a patient can be accurately assessed within a limited timeframe [26]. The absence of bedside communication skills is a major factor contributing to underperformance among nurses [27]. The findings of this study indicate that communication skills are significant factors affecting ED nurses' triage competency. Triage involves making decisions based on the patient's condition, and previous studies conducted among Korean nurses have emphasized the importance of communication skills in the decision-making process [28], aligning with the results of this study.

When a surge in volume occurs, having access to the available resources is relevant for thoroughly assessing each patient and ensuring the correct treatment. This is of particular concern since poor or missing information may result in incomplete or faulty patient assessment [29]. Engagement with patients is a possible facilitator for accurate triage. Since the ED lacks information about patients compared to other departments, nurses' communication skills are important in terms of eliciting statements and opinions from patients.

In Model II, grit was identified as a factor influencing the triage competency of ED nurses. Grit motivates nurses to withstand challenges and succeed over time. Cultivating grit among clinical nurses is important to maintain their interest in emergency preparedness and to ensure that the needs of patients and caregivers are met [30]. At times, critical patients can be admitted to the ED's special work environment. grit can impact triage competencies as it enables nurses to approach triage with a sense of challenge rather than fear. A study conducted with Colombian healthcare providers corroborates our findings, indicating that grit negatively correlated with decision fatigue [31]. Grit is recognized as a personality trait that may serve as a protective factor against compassion fatigue and decision fatigue [31]. However, when self-leadership and communication skills were incorporated into the final model, grit did not emerge as a significant variable. A study suggests that there is no significant correlation between the disaster triage ability and grit of ED nurses in Korea [32]. Research on grit has been limited and the results have been inconsistent. Therefore, further research is warranted to gain a more comprehensive understanding of this topic.

The results showed that education level, and triage experience had explanatory power in Model I. Previous studies have suggested that higher education levels contribute to increased knowledge and experience in triage, enabling nurses to handle a wider variety of patients [33].

Despite their extensive clinical experience, nurses have reported encountering similar challenges when problem-solving within a resource-limited, comprehensive triage system [34]. Experienced nurses often rely on rapid observation or intuition, but the importance of data collection and confirmation has been emphasized [34]. Appropriate triage education programs should be implemented for both new and experienced nurses, with ongoing development at regular intervals. Practical guidelines and comprehensive classification processes should be included in educational programs, and simulation programs or standardized curricula have been identified as high-quality educational methods. Interactive and ongoing education and training are crucial due to the significant role of triage nurses in determining the treatment order [35], which affects patient safety and prognosis. Further research on the roles of knowledge and experience in triage competency could inform the development of education programs and improve decision-making outcomes.

Our study has implications for emergency clinical practice. Novice nurses may lack both experience and opportunities to improve their self-leadership and communication skills. This can present a major obstacle in terms of accurately determining the severity of a patient's condition in a short time. Therefore, improved work culture and educational programs can make it possible for nurses' mistakes during work to be seen as a learning opportunity rather than a failure, and this shift will further improve triage competency.

This study has several limitations. First, the study participants were ED nurses who worked on triage in EDs of general and tertiary general hospitals in an Incheon metropolitan area, which limits the generalizability of the findings to other EDs. The sample size was also relatively small (n=152), which may affect the statistical power and generalizability of the results. Second, since the triage competency survey instrument is self-reported, ED nurses may have overstated their responses; therefore, an objective evaluation of the accuracy of assigned triage scores may be necessary. Third, the study focused on the relationship between self-leadership, communication skills, grit, and triage competencies, and it did not explore other potential factors that could influence triage performance. Factors such as teamwork, organizational support, and workload could also play a role in nurses' triage competency. Future studies could incorporate a broader range of variables to gain a more comprehensive understanding of the factors influencing triage performance. Fourth, the cross-sectional design of the study limits the ability to establish causal relationships between the variables. Longitudinal or experimental studies would provide stronger evidence for understanding the impact of self-leadership, communication skills, and grit on triage competency. Fourth, two of the survey instruments utilized in this study—namely, those for self-leadership and communication skills—were originally developed in 1983 and 2003, respectively. Subsequently, modifications were introduced in 2002 and 2010 to enhance their applicability and relevance. However, since considerable time has elapsed since their original development, it is important to carefully consider their alignment with contemporary contexts while selecting these instruments for potential future measurements. Lastly, this study included head nurses, and it is not common for unit managers, such as head nurses, to perform patient triage in the ED. Additionally, among the study participants, some nurses reported not having received triage education. Considering that nurses typically perform triage after receiving relevant training, it cannot be ruled out that nurses who do not actually perform triage were included in the study. Therefore, careful interpretation of the study's results is necessary, and further research considering these limitations is needed.

The findings of this study highlight the significant role of self-leadership, communication skills, and triage experience in explaining ED nurses' triage competency, emphasizing the importance of improving self-leadership to enhance triage competency in nurses. Effective communication skills were identified as crucial factors influencing the triage competency of ED nurses, emphasizing the need for comprehensive communication training programs to ensure accurate patient assessment and decision-making within limited timeframes. While grit showed an initial influence on triage competency, its significance diminished when self-leadership and communication skills were considered, suggesting the need for further research to better understand the relationship between grit and triage competency in ED nurses and its potential role in addressing decision fatigue. The study provides valuable insights into the factors influencing triage competency and highlights the importance of continuous education, training, and creating a supportive work culture in EDs to enhance the skills and performance of ED nurses in triage settings.