The increased responsibility of nurses in advanced medical treatment in primary care settings represents a new development internationally, and may require development of new patterns of inter-professional collaboration. According to the interviewed physicians, nurses were responsible for managing the treatment prescribed by physicians, and their qualification in this area was an essential element in the provision of quality services. Our analyses revealed that broad medical knowledge, advanced clinical skills, ethical qualification and a holistic approach are considered important nursing qualifications for providing care in municipal emergency inpatient units. The ability to make overall assessments of situations and adopting a family perspective in care and treatment was considered essential.
The interviewed physicians highlighted the importance of broad medical knowledge when working in local emergency units, as patients often have multiple diagnoses and complex conditions. This need is also highlighted in Norwegian national policy documents (Helse- og omsorgsdepartementet, 2015), and is substantiated by research (Hole et al., 2015; Bing-Jonsson et al., 2016; Vatnøy et al., 2019). An increased demand for nurses with skills in managing a more diverse, complex and acutely vulnerable patient population is also described globally (Duffield et al., 2009). This demand has led to the creation of advanced practice positions for nurses. Core competencies in advanced practice nursing include clinical care, collaboration, coaching and guidance, leadership and ethical decision-making (Dowling et al., 2013).
In the present study, the importance of nurses’ clinical competence and experience was especially highlighted. Transferring advanced treatment to local community health services increases the demand for advanced clinical skills in this setting. A tremendous shift of responsibility from physicians to nurses in all healthcare settings has occurred over the past 60 years (Benner, 2010). Benner (2010) stated that the early identification of changes in patients’ physical conditions in acute and long-term care facilities is crucial to the safety and well-being of vulnerable patients. This finding is supported by the assessments made by the physicians in the present study. Consequently, sound clinical judgement, the ability to manage treatment, and to precisely and systematically report the patients’ condition to the responsible physician were highlighted by the physicians as important qualifications for nurses to have to ensure patient safety.
Several physicians emphasized the need for screening tools to identify nutritional risk in patients admitted to local emergency units. A Norwegian study identified several obstacles preventing the use of screening tools for nutrition in hospitals (Juul & Frich, 2013). These included poorly defined roles, poor leadership involvement and inadequate nutritional knowledge. Factors that facilitated the use of such tools were good documentation systems, coding for undernutrition and physicians’ commitment to and request for nutrition-related data. The study concluded that nutrition treatment should be aligned with other types of treatment. Defined roles and responsibilities with respect to nutritional screening also seem to be lacking in municipal emergency units.
Other forms of qualifications than those identified in the present study have also been advocated (Martinsen, 2006). Martinsen (2006) envisioned a more humanistic approach as a necessary supplement to evidence-based practice in care. Martinsen (2006) noted the meaning of language in understanding patients and the way they are seen. A standardized practice can block patients’ narratives and prevent alternative understandings of the patient’s care. The interviewed physicians expressed that they wanted nurses with ‘life experience’. This might be what Martinsen (2006) highlighted as an ethical dimensions of caregiving. She express that this always should be present in the interaction with a patient and their family care givers. To support this kind of thinking, health personnel, patients and next of kin together should discuss to identify the best choices from the perspective of the patient. From an educational perspective, preparing nurses to interact with patients in vulnerable phases of illness and life situations requires the inclusion of various forms of knowledge. White Paper 26 (Helse- og omsorgsdepartementet, 2015) on primary healthcare services in Norway called attention to the need for advanced clinical nurses with a master’s level of education and with broad qualifications, which enable them to address the complex situations that arise in local health practice. In this study, the interviewed physicians emphasized the importance of nursing qualifications that cannot be taught at the university. Benner’s (1984) description of the qualification process from novice to expert sheds light on learning in practice. Novice nurses learn context-free rules and theories that are functional in their daily practice. Advanced beginners understand the patient situation better, but are still dependent on procedures and need assistance in clinical work. Competent nurses are those who have worked with certain types of patient situations for two to three years, and consequently understand their work in a larger context. These nurses can prioritize on the basis of this analytical competence. During the next stage, nurses develop a more general understanding, which enables them to see various patient situations from different perspectives. Nurses with this level of understanding are better able to detect changes in a patient situation at an early stage. Expert nurses are those who are able to work almost intuitively from a deep general assessment of the situation.
According to Benner (1984), the journey from novice to expert involves three types of change: (a) a change from the use of abstract principles to the use of concrete experiences, (b) a change from a fragmented understanding of a situation to a more general understanding and (c) a change from observation to participation. Benner’s (1984) model of the learning process illustrates that it takes time to develop expert competence in local emergency units.
This study shows that nurses in municipal emergency inpatient units need to have advanced qualifications. Sullivan (2004) put forward a clear message to educational institutions: the most important task is ‘to form practitioners who are aware of what it takes to become competent in their chosen domain and equip them with the reflective capacity and motivation to pursue genuine expertise’ (p.253). White Paper 16 (Ministry of Education and Research, 2017), titled ‘Quality Culture in Higher Education’, and highlights the importance of social and emotional qualities, critical thinking, community conscience and self-reflection. Municipal emergency inpatient units place special demands on communicative and cooperative abilities of their health personnel. Nurses must have compassion (Crawford et al., 2014) and the will to find individual solutions so that they can offer compassionate care to their patients in emergency care.
This study was reported in accordance to the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ) (Tong, Sainsbury & Craig, 2007). These findings should not be generalized (Polit & Beck, 2017), but it is likely that they can be relevant in other settings where nurses have corresponding responsibilities.
A limitation is that two of the three groups comprised only three physicians. However, these physicians all had long experience and good knowledge about the competence situation in municipalities. Rich data were collected because the physicians showed good insight and engagement in the topic asked.
Nurses need advanced ethical qualifications, which integrate broad medical knowledge, advanced clinical skills and the ability to take a holistic approach. They have a considerable responsibility to work independently and safely in a setting where both the patient and the patient’s family play important roles. Establishing arenas for collaborative practice between physicians and nurses on clinical issues may be a way of strengthening patient safety and nurses’ clinical judgement.
Professionals in the education nurses and physicians should cooperate to prepare their students for new patterns in inter-professional work with respect to the transition of emergency care to municipalities.