Central administration

Scenario ‘Business as usual’

Two panellists chose chosen this scenario as the most probable, and one as the most desirable.

Some kind of mix of scenarios I and II was anticipated to be the most probable future by one panellist.

Centralisation of emergency health care services

The centralisation of emergency health care services was not commented on by this sub-panel, either.

Education of nurses

However, it was mentioned that education of nurses, providing insufficient practical preparedness, has not been intensified sufficiently that it would have been possible to get even close to an independent ED nurse’s profession as described in scenario II. On the other hand, that scenario (II) outlines such tasks for nurses that according to the legislation prevailing at the time of inquiry have been solely dedicated to the medical profession.

Nurses increased responsibilities

One panellist considered the whole idea of ‘a reception of minor illnesses and injuries’ within an ED absurd:“Those belong to be treated in primary care!”Changes to this scenario were suggested, as follows: “The scenarios could have been seasoned by some visions of the changes in morbidity and its possible effects on the workload – in this study ED nurses only pay attention to themselves.”

The probability of scenario I was mentioned to having been promoted by issues as follows:

“Other parts of our health cares system, especially primary and home care are starting to take their responsibilities remarkably better than currently. That leads to diminishing emergency health care problems for example within the geriatric population. Parts of scenario II will complement the current model (scenario I), especially the standardisation of working processes, redistribution of tasks to some extent and systematic development of competencies including evidences of keeping up the competence.”

Scenario ‘ED nurses’ profession is evolving’

Four members of this sub-panel considered this scenario as the most probable and six as the most desirable one. This scenario was said to contain many such elements as have already been realised in many countries, e.g. in the USA and GB.

Centralisation of emergency health care services

ED actions have been, along with the established municipality reformation and because of cost-cutting efforts, centralised even more. A policy of having a triage nurse in each shift has been absolutely necessary in centralised EDs. Positive experiences from similar actions within large operating units have previously been gathered.

Education of nurses

“I would regard scenario II, when implemented well controlled, as desirable. This kind of enhancement of the preparedness of emergency health care services at out-of-office hours for those needing immediate help would provide additional reasons for further centralisation of demanding health care services.”

The progression of the profession according to scenario II has been possible in those big EDs that had already begun to develop at the time of inquiry. Nurses with candidate and master’s level education have formed only a part of ED nursing and that has required nursing and medical leaders to be capable of visionary management. A gloomy outlook for those EDs where they had not already to think about the visions outlined in scenario II and business has gone pm as usual, is evident. Scenario I, or at its worst, scenario III, has been realised.

Development has not depended merely on the management, but it has also been about a certain lack of professionalism and vision. At its worst, even the value and possibilities of further education have not been understood. These kinds of units have been commonly found in Finland.

The worst choice has been that either the personnel or the management has not understood the trends of and demands for development. The developing of an ED has taken more than ten years and required unconditional systematic work from both the management and staff. It has also required that universities, universities of applied sciences, and the world of work have planned and executed this vision together. The support of health care districts’ management has also had to be behind this.

These issues came up strongly in the discussions. The central administration had become aware of them in terms of the progress of medicine and nursing, mastering of entities, competence and economic efficiency. A strong emphasis had been place on taking care that manual skills were developed; the educational programmes must have included enough long periods of clinical practice in different working circumstances.

Even more specialisation for emergency nursing has been needed, but the education has occurred in connection with further education at universities of applied sciences, and only some have received a university degree. Further education at universities of applied sciences represents at such a high level as to have equalled a ‘nurse practitioner’ educational programme. A university level degree has equalled a so called ‘advanced nurse practitioner’

programme. Further education to master’s level has also been provided as specialisation and additional education at universities of applied sciences. Persuading MDs to provide education may have emerged to be a problem. At least in the beginning of such educational programmes the education cannot have been provided by the nursing profession itself. Part of this kind of education has required MDs to provide it, even though some of the educators have been emergency nurses with special education.

A point of view was presented as an obstacle for scenario II to having been realised. Within our nursing education, the approach has been to improve a nurse generalist’ s competences.

As the education time has always been limited this may have led to superficiality of acquired competences, while profound competencies may have been in danger of being left aside.

An interesting suggestion was made: “Maybe we would need a totally new health care educational programme for patients with substance abuse problems. It might be useful also in the ED.” Patient safety has risen to be a priority within all health care educational programmes and management. Development of the processes has also had an impact on reducing the incidence related to multi-resistant bacteria.

Nurses’ increased responsibilities

Nurses’ independent working has increased, and tasks have been redistributed to them from MDs. At the same time more responsibility for patients’ holistic care has been allocated to nurses. It has not been a question of distribution of some individual tasks. In connection with the distribution of work, nurses’ counselling and education work has been emphasised as well as the co-ordination of a patients’ care, which have for a long time been done by nurses working in EDs.

The distribution of work between different professionals has been reorganised especially as the use of hired MDs in the EDs has increased. The medical profession has become more and more female, and female MDs have not been so willing to take care of on-call duties, especially in those laborious EDs. We have had to increasingly trust in the hired MDs. This has meant that the permanent staff, including specially educated nurses, have had to take more responsibility for general organisation and action. Department unit managers have become more like managers and department leaders in EDs, where different specialists, including MDs, have been providing their specialist services.

It has taken years to reduce MDs’ traditional entitlements, mainly because of the heavy resistance of their trade union. Certain alleviations have taken place in the form of nurses’

restricted right to prescribe, and entitlement for writing certifications for sick leave. However, MDs have not given up their entitlement for setting a diagnosis and making decisions concerning the patient’s care. It has been questioned whether even that is necessary, even though it is in any case action in accordance with an MD’s expertise and education.“All the work cannot and should not be redistributed”, as one respondent has described.

Economic pressure has led us to transfer tasks from MDs to nurses. This has, however, been everyday routine in the pre-hospital settings. This can have been seen as one way to withstand the ever developing lack of personnel, by providing challenging tasks at magnet hospitals.

It has been necessary to hire also a work force with lower level of training to EDs, for routine and supportive purposes: “If there should appear some kind of dividing of personnel into castes, it will touch other expanded scopes of practices, as well.”Furthermore, these have been issues of management and culture.

Working in multi-professional teams, so that the professional competence of everyone has its place, has increased remarkably. Nursing personnel have been well motivated and their wages

have been determined on the basis of the demands of their work and personal qualifications.

This has, in turn, inevitably raised the level of salaries in the EDs. The importance of EDs has increased and they have been resourced accordingly. Thus ED work has been desired and problems in acquisition of staff have not been especially encountered when there has existed a dedicated educational programme for ED nursing purposes.

Miscellaneous

“The most probable scenario will be found somewhere between I and II.” Factors that have promoted the realisation of scenario II have been as follows: “This would enable to scrutinise the process of a patient’ s care as a whole, home – pre-hospital EMS – ED. Part of the patient’s health problems could be taken care of by ED in co-operation with primary and home care. Other parts of specialised medical care would be able to focus on the development of elective processes.”

It has not been certain that the processes of a hospital have been guided by the protocols adopted in the ED as a starting point. A perception of the action that has been desired has guided the distribution of work and the development of competencies.

The emphasis placed on the independence of professions was considered to have been an unwanted word. It would have been better to translate it to the language of working processes and the success and competence of teams; thus it might have turned out to be a promoting factor. This was a point of view that should have been specified within the scenarios:

“Regular assessment of theoretical knowledge and clinical skills may lead to administratively burdensome and expensive solutions. The re-assessment of competence might be appropriate according to certain criteria, e.g. when protocols of care are changing or the scope of practice is increasing, or after a long absence from work.”

A suggestion was made that the co-operation and teamwork of MDs and emergency nurses could have been described in terms of their meaning and precondition. They both have needed each other in order for the model to work.

Acting according to the scenario has not, however, prevented all the problems: “Complaints have still been made. Their processing both with patients and multi-professionally, as well as making use of the information produced by the complaints, has intensified.”

Scenario ‘The system is in danger of collapsing’

Two members anticipated the most probable future to be as described in this scenario:“This will be our future, unless it is quickly invested in education and development according to scenario II.”Issues also to be implemented quickly were mentioned to be the availability of personnel resources, wages and the processes of action in the EDs: “This will be the consequence, if we can’ t manage to lift up the profile of ED work. This is related to the working of other components of health care organisation – primary care, pre-hospital EMS etc. all work apart.”