Triage under pressure: Nursing students’ learning and preparedness in a code orange simulation using CTAS
- 1Nursing, Brock University, St. Catharines, Ontario, Canada.
Abstract
Background: Preparing nursing students for mass casualty incidents requires more than foundational knowledge; it demands the ability to apply triage principles under pressure. While simulation-based education is widely used, there is limited evidence examining how students integrate established triage frameworks, such as the Canadian Triage and Acuity Scale (CTAS) and Glasgow Coma Scale (GCS), within high-acuity disaster contexts. This study evaluated nursing students’ knowledge application, clinical prioritization, and perceived preparedness following a Code Orange simulation. Methods: cross-sectional survey was conducted with undergraduate nursing students (n = 26) following participation in a high-fidelity Code Orange simulation. The survey included multiple-choice knowledge items assessing CTAS and GCS application, Likert-scale measures of perceived knowledge, confidence, and preparedness, and open-ended questions exploring student experiences. Quantitative data were analyzed using descriptive statistics and Chi-square tests, while qualitative responses underwent content analysis. Results: Participants demonstrated strong knowledge of CTAS and GCS principles, with most correctly identifying triage priorities and neurological assessment parameters. Variability was observed in students’ ability to distinguish between CTAS Levels 2 and 3, with recognition of vital signs as a key differentiator (χ² = 57.18, p < .001). Likert-scale responses indicated high levels of perceived preparedness, confidence, and knowledge following the simulation. Qualitative findings highlighted the importance of realism, cognitive demand, and teamwork in shaping learning, with students emphasizing the value of applying theoretical knowledge in a dynamic, high-pressure environment. Conclusion: Findings suggest that high-fidelity disaster simulations extend beyond reinforcing baseline knowledge by promoting the application of triage decision-making in complex clinical contexts. Integrating structured triage frameworks within immersive simulation may enhance preparedness for mass casualty response, particularly in areas requiring nuanced clinical prioritization. These results underscore the role of simulation in bridging the gap between theoretical knowledge and real-world emergency decision-making.
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BibTeX
@article{silva2026triage,
title = {{Triage under pressure: Nursing students’ learning and preparedness in a code orange simulation using CTAS}},
author = {Vanessa Silva E Silva and Magdalena Dobosiewicz and Karina Tamy Kasawara and Emily Bot and Sylas Coletto and Rebecca Larocca and Shelley Oakes and Tori McDowall and Dawn Prentice and Amina Silva},
journal = {PLOS One},
year = {2026},
month = oct,
doi = {10.1371/journal.pone.0360652},
url = {https://doi.org/10.1371/journal.pone.0360652},
note = {CC BY},
}
RIS
TY - JOUR
TI - Triage under pressure: Nursing students’ learning and preparedness in a code orange simulation using CTAS
AU - Vanessa Silva E Silva
AU - Magdalena Dobosiewicz
AU - Karina Tamy Kasawara
AU - Emily Bot
AU - Sylas Coletto
AU - Rebecca Larocca
AU - Shelley Oakes
AU - Tori McDowall
AU - Dawn Prentice
AU - Amina Silva
PY - 2026
DA - 2026/10/30
JO - PLOS One
DO - 10.1371/journal.pone.0360652
UR - https://doi.org/10.1371/journal.pone.0360652
AB - Background: Preparing nursing students for mass casualty incidents requires more than foundational knowledge; it demands the ability to apply triage principles under pressure. While simulation-based education is widely used, there is limited evidence examining how students integrate established triage frameworks, such as the Canadian Triage and Acuity Scale (CTAS) and Glasgow Coma Scale (GCS), within high-acuity disaster contexts. This study evaluated nursing students’ knowledge application, clinical prioritization, and perceived preparedness following a Code Orange simulation. Methods: cross-sectional survey was conducted with undergraduate nursing students (n = 26) following participation in a high-fidelity Code Orange simulation. The survey included multiple-choice knowledge items assessing CTAS and GCS application, Likert-scale measures of perceived knowledge, confidence, and preparedness, and open-ended questions exploring student experiences. Quantitative data were analyzed using descriptive statistics and Chi-square tests, while qualitative responses underwent content analysis. Results: Participants demonstrated strong knowledge of CTAS and GCS principles, with most correctly identifying triage priorities and neurological assessment parameters. Variability was observed in students’ ability to distinguish between CTAS Levels 2 and 3, with recognition of vital signs as a key differentiator (χ² = 57.18, p < .001). Likert-scale responses indicated high levels of perceived preparedness, confidence, and knowledge following the simulation. Qualitative findings highlighted the importance of realism, cognitive demand, and teamwork in shaping learning, with students emphasizing the value of applying theoretical knowledge in a dynamic, high-pressure environment. Conclusion: Findings suggest that high-fidelity disaster simulations extend beyond reinforcing baseline knowledge by promoting the application of triage decision-making in complex clinical contexts. Integrating structured triage frameworks within immersive simulation may enhance preparedness for mass casualty response, particularly in areas requiring nuanced clinical prioritization. These results underscore the role of simulation in bridging the gap between theoretical knowledge and real-world emergency decision-making.
SN - 1932-6203
ER -