This is the first in a series of reports to share key learnings from my sabbatical. In the spring and summer of this year I took a three-month journey through Scandinavia, Europe, Ireland and the United Kingdom to observe innovation in nursing service delivery and, in particular, nursing-led services; to explore outcome measurement as it relates to nursing services; to look at patient satisfaction and improving the patient experience as a form of outcome measurement; to learn about palliative care; and to examine ways in which different organizations, professional associations and policy-makers are attempting to move nursing care and healthcare services delivery into the future.

I visited Norway, Sweden, Denmark, Germany, Holland, Belgium, France, Ireland, Scotland and England, where I met with nursing leaders, professional leaders and associations, policy-makers, faculty and research units. During site visits, I was able to spend time with practising nurses to observe their work. I visited teaching hospitals, district or community hospitals, community services, hospices and telehealth facilities. Our international colleagues extended a warm welcome, helped me gain exposure to things that might be of interest and were eager to learn about our practices in Canada. In this report, I want to share with you the liberation of nursing in various countries. This is the development of "maxi nurses, not mini doctors" in the United Kingdom. Nurses in advanced practice roles initiate diagnostics and treatment, manage the care of patients and move them effectively through the healthcare system to achieve positive patient outcomes, prevent admissions and reduce lengths of stay and overall cost.

Nurses in Norway, Sweden and Denmark function as anaesthesia nurse specialists and administer anaesthetics independently in a team with anaesthetists under medical directives. Nurses in Germany work as nurse anaesthesia assistants in a team with anaesthetists and support pain management. In France, nurses administer anaesthetics under the direction of physicians.

Accident and Emergency Departments in Ireland are staffed by advanced practice nurses as well as nurse specialists, such as respiratory nurse specialists and chest pain nurse specialists, who focus on those key populations presenting to the Emergency Department. An advanced practice nurse also functions as a liaison with referring physicians. All practitioners work under medical directives and initiate diagnostics and treatment in partnership with physicians to the level required based upon the acuity of the patient.

Emergency Department-associated clinics and units that are nursing-led decant patients of different types. For example, nursing-led clinics operated by advanced practice nurses were reported for Colles' fractures, renal transplant, bone marrow transplant, syncope, and stress and urge incontinence. A nursing-led Chest Pain Assessment Unit provides 24-hour follow-up and continuous monitoring that has been instrumental in identifying acute issues in patients who would otherwise have been discharged home from the Emergency Department without support. Elderly patients who are admitted to Medicine from the Emergency Department go to an Acute Geriatric Medical Assessment Unit and have the support of geriatrics advanced practice nurses with a focus on intensive assessment, treatment and discharge home. Integrated health service delivery models also support the Emergency Departments in Ireland. Services such as Hospital in the Home provide nursing and physiotherapy services for respiratory patients. A Shared Care Discharge Team provides nursing and occupational therapy for patients in the first 12 days after discharge. These services prevent hospital re-admissions and shorten lengths of stay.

Strategies to consolidate and strengthen access to Accident and Emergency Departments have been put in place in Scotland. For example, the consolidation of one hospital Emergency Department in Edinburgh and the conversion of another hospital Emergency Department to a nursing- led Minor Injuries Clinic has been successfully implemented. Associated with this clinic is a nursing-led Deep Vein Thrombosis Outpatient service that prevents five- to six-day hospital admissions.

Strategies to meet the four-hour target from door to admission through Accident and Emergency Departments in England are led by nurses implementing advanced patient assessment and working as a team, under medical directives, with physicians to initiate assessment, diagnosis and treatment immediately upon arrival at the Emergency Department. Acute Medical Assessment Units, staffed by advanced practice nurses dealing with emergency medical admissions for the first 24 hours, in association with a Short-Stay Unit for an additional 24 hours, result in intensive patient management and early discharge. Advanced practice nurses manage surgical admissions with a 30% discharge-to-home rate and a decreased length of stay of 1.2 days. Physio triage for pre-operative patients has resulted in a 20% reduction in the need for surgery, thereby reducing surgical wait lists. Advanced practice nurse management of fractured neck-of-femur patients has resulted in significant reduction in lengths of stay and mortality. Advanced practice nurse management of major abdominal pain has resulted in a reduction of time in the Accident and Emergency Department. Nursing-led clinics have helped streamline the management of patients and focus on such areas as cataracts, glaucoma, colposcopy and urogynaecology. A nurse- initiated thrombolysis program is in place. Paramedic-administered thrombolysis is supported by hand-held ECG consultation with the Accident and Emergency Department. Other nursing- led services that defer admissions and reduce lengths of stay include A Ward in the Community, which integrates acute, emergency and community services.

As you can see, our colleagues in Scandinavia, Europe, Ireland and United Kingdom are liberating nurses in advanced practice roles to improve the management of patients throughout the continuum of care. We can learn from our international colleagues about expanding these roles and developing nurse-led clinics and units in a variety of applications to achieve positive outcomes for patients and practitioners. There are clearly opportunities for us to put broader nursing and allied health roles in place to improve quality of care for patients and efficiency in our healthcare services.

I look forward to sharing other key learnings with you in future reports.

About the Author

Mary Ferguson-Paré, PhD
Vice President, Professional Affairs and Chief Nurse Executive
University Health Network,
Toronto, ON