A new profession in the pre‐hospital care field – the ambulance nurse

Historically, the ambulance service has been viewed as an organization responsible for the transportation of sick people into hospital, but as a result of advances in surgical techniques, resuscitation and pharmacology, this has led to the discipline of pre-hospital emergency care becoming established and recognized as an important part of the patient's total care. In addition, medical and technical developments have led to pre-hospital emergency care becoming a kind of advanced nursing and an important first link in the chain of care. This has resulted in the emergence of a new discipline of ambulance nurses. Their entrance onto the scene is gradually changing and developing the ambulance service. Nurses with a background in anaesthetics, intensive care and cardiology units have for many years been employed for pre-hospital work (Suserud et al. 1998). In Sweden, nurses, and in particular anaesthetic nurses, have been increasingly used for pre-hospital work in Mobile Intensive Care Units (MICU) and on medical emergency teams. These nurses have traditionally taken an active part in the intra-hospital routine treatment of patients with complex conditions and who are clinical unstable. Medical directors' and ambulance chiefs' views have been that those nurses who are used to working independently and have competence in advanced life support are suitable for this role. I also think that many of them, as well as many ambulance nurses, are attracted to working at the front line. However, I would say that most are not prepared for the diversity of patient they will meet outside the acute hospital. The ambulance nurse needs a broad knowledge base and skills to apply or adapt to the care of patients in different settings. When ambulance nurses meet a patient in the home or on an accident site, they must gather information and be open for all information about and from the patient. Data about the patient should lead to an assessment and decision about what should be done immediately. They have to rely on experience to reveal patient needs, which could be complex in such circumstances and can be physical, emotional, social and cultural in character. They have to be prepared for the unexpected (Wireklint Sundström, 2005), this is not untypical of many critical care settings and may explain why nurses from these areas are attracted to working as ambulance staff. Another factor when making assessment is the possibility of ambulance nurses being the only professional with medical responsibility on the scene. Meeting someone's needs in their home or at the scene of an accident is a totally different situation from the high-tech area of, for example, an intensive care unit where you have a back-up of physicians and other nurses. However, there are still professionals (Kronohage, 2005) who argue that having anaesthetic nurses in the ambulance service would be valuable due to their skills in, for example, airway management. Of course, there is a need for knowledge of emergency situations, but it is important to note that only 10–20% of ambulance missions involve life-threatening conditions with acute disturbance of vital functions. This implies that the ‘chance’ of involvement in severe accidents varies, and in some ambulance districts there are months between those exclusive moments. One has to remember that the golden rule at an accident site, or other pick-up point, ought to be optimal care, rather than maximal care. The opportunity for pre-hospital personnel to mix intra-hospital and pre-hospital work (i.e. the Emergency Department) is therefore an essential point to consider in the scheduling of personnel who can gain valuable experience from frequently practising medical measures and meeting patients in all phases of care. The Swedish National Board of Health and Welfare considers that the demands in pre-hospital emergency care (including MICU and helicopter) require registered nurses with special education and a specialist training in ambulance nursing. The Board also claims that there is an extensive need for an overall higher competence within the ambulance services, because the same standards of safety concerning diagnoses and therapy are applicable in pre-hospital emergency care as in all other hospital care. The nurse's role has been defined and the importance of clear regulations about responsibility within the ambulance services has been stressed. In a recent description of the role of nurses involved in pre-hospital care, the Board stated that the nurse must have responsibility for nursing care, certain examinations and specified medical treatment; give information to patients and relatives; supervise colleagues and students; be updated on and participate in research; plan and lead work in the pre-hospital field and co-operate with other professionals; and be part of the command function and take care of injured at the disaster site. A regulation from the Swedish National Board of Health and Welfare implies that by 30th September 2005, every emergency ambulance should be staffed by at least one registered nurse (SOSFS, 1999:17). This is because only nurses are permitted to dispense and administer drugs according to well-defined standing orders. Without a registered nurse in the ambulance, no drugs may be given to the patient. The development of the ambulance nurse has led to discussions as to whether there is any real need for additional training aimed only at functioning within the ambulance services. Some argue there is a great shortage of emergency nurses in hospitals and therefore recruitment to this speciality should be prioritized. This kind of view can be seen as a conservative reaction from those who want to hold on to the old system with only ambulance paramedics in the ambulance service. The patient has the right to meet the same standard of care and the same competence on front professionals in pre-hospital care as in hospital care. Ambulance nurses are paid more than ambulance paramedics and have taken over most of the nursing care and treatment of the patient. Prior studies (Suserud and Haljamäe, 1997, 1999) have shown that some paramedics are threatened by nurses entering the field of pre-hospital emergency care and are afraid of being classified as ‘second class team members’. There are different ways of solving such rivalry between professions. In many districts, paramedics are given the role of being responsible for technical procedures, equipment and radio and data communication. As mentioned earlier, the ambulance nurse is always responsible for the medical care if a physician is not present. However, on a majority of ambulance crews, the combination of staff with different levels of competence already exists, and this does not cause any problems. Generally, nurses are aware of the fact that they can learn from experienced paramedics and that working together ensures good quality pre-hospital care for the patient. The competence of a nurse, in an emergency team along with a well-educated paramedic, is now seen as the best Swedish model of care for injured or critically ill patients requiring ambulance transport. In Sweden, today, there are four areas of specialist education within emergency nursing, each of which is a 1-year programme at the masters level (Suserud, 2001). These areas are ambulance nursing, anaesthetic nursing, intensive care unit nursing and peri-operative nursing (theatre nurse). The criterion for entering these programmes is a Bachelor in Nursing. It should be noted that these programmes are aimed at producing nurses who also have the ability to tackle research problems and to develop methods of improving quality in the field. This programme can be complemented with a further 1 year resulting in a 2-year masters in the subject according to the European agreement in Bologna. All nurses working in the ambulance services are to some extent pioneers and have just begun to be a major influence in this area. More women are now involved (as most nurses are females), and this will surely affect the culture at ambulance stations in a positive way. Although ambulance nursing is still the specialist education that attracts most males, the number of female nurses is increasing at all ambulance stations. In the course at the University College of Borås nearly 50% of students are men, while other specialist nursing programmes have less than 20%. The involvement of nurses with such specialist training should vastly improve the quality of pre-hospital emergency care. The new formalized training for nurses in pre-hospital emergency care may also pave the way for better medical assessment and treatment of critically ill patients and a more clearly defined role for nurses in pre-hospital emergency care-related research. Some discussions have questioned the ability of women to function well in the pre-hospital emergency care. Work in the ambulance service is, however, comparable with the work that nurses regularly do in hospitals and other institutions, and not many have questioned their capability to manage work in these situations. It is quite likely in the future that the nurse will play an even more central part of pre-hospital emergency care in Sweden and hopefully also in other countries.