Triage under pressure: Nursing students’ learning and preparedness in a code orange simulation using CTAS

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.