Extended Nursing Capability Beyond Traditional Boundaries

Aim

To improve timely access to meaningful treatment in emergency and urgent care settings  by activating and credentialing experienced registered nurses to practice at the top of their scope under robust clinical governance.

Outcomes

• Across pilot sites (February 2025 – July 2025)
• Reduced median wait times for low acuity  presentations.
• Earlier access to analgesia and initiation of treatment.
• Reduced length of stay for protocol eligible patients.
• Decreased routine escalations to medical officers for guideline driven care.
• Improved patient flow across peak demand periods.
• Increases staff confidence, autonomy, and interdisciplinary collaboration. No increase in FTE was required.100% reporting that the interprofessional peer supervision sessions enhanced their placement experience and improved their clinical practice.

Background

EDs across Queensland are experiencing sustained growth in demand, workforce shortages,  and increasing expectations to deliver safe, timely, and efficient care. A significant proportion of presentations involve low acuity, protocol-based conditions require timely assessment, diagnostics, and treatment but do not necessarily require complex medical  decision making. Despite this, patients frequently experience delays while waiting for medical officer review, contributing to prolonged waiting times, extended length of stay, emergency department overcrowding, and reduced patient satisfaction.

These delays  also increase system inefficiency, contribute to staff workload pressures, and limit the ability of services to meet performance and access targets. At the same time, experienced emergency nurses possess advanced clinical assessment capability, procedural
skill, and contextual knowledge that remains underutilised within traditional scope boundaries, highlighting a mismatch between workforce capability and workforce deployment. Metro South Health’s strategic priorities emphasise workforce optimization, improved
patient flow, and delivery of care in the most efficient and sustainable way.

Within this context, the Extended Practice RN Model was developed to address a critical and clearly defined system challenge: how to expand access to safe, timely care and improve  emergency department performance without increasing workforce numbers or compromising clinical governance. The central problem addressed by the project was not a lack of clinical capability within the workforce, but the structural and regulatory limitations  that prevented experienced registered nurses from practicing at the top of their scope within clearly defined, evidence-based protocols. Building on the Executive sponsored Protocolised Care Project, the EP-RN model reimagines workforce deployment through  role optimization rather that role substitution. It enables experienced emergency nurses to deliver protocol-based assessment, initiate diagnostics, and administer or supply treatment doses of approved medications within structured Health Management Protocol  guidelines aligned with legislative and governance requirements.

Formal credentialing, defined scope of practice, and clear escalation pathways ensure patient safety, accountability, and compliance with professional and regulatory standards. This approach  preserves the collaborative, multidisciplinary model of care while enabling more efficient allocation of clinical resources. This model directly addresses key operational and workforce challenges, including delays to meaningful treatment, inefficient use of  highly skilled nursing staff, and increasing demand without proportional workforce growth. By enabling care to be delivered by the most appropriate clinician at the most appropriate time, the EP-RN model improves system responsiveness while maintaining safety  and quality. This approach strengthens workforce capability, enhances professional autonomy, and supports workforce sustainability by providing a structured extended pathway for experienced nurses, while also establishing a formal succession pathway planning  platform that prepares and transitions clinicians toward advanced practice and future Nurse Practitioner roles.

This is Workforce Without Walls: removing unnecessary professional and process barriers while preserving safety, governance, and team-based care.  The EP-RN model demonstrates how structured workforce redesign can improve access, efficiency, and patient experience, providing a scalable and sustainable solution to ongoing emergency care demand across Queensland Health.

Discussion

The EP-RN model demonstrates that workforce redesign, rather than workforce expansion,  can sustainably improve emergency department performance while maintaining safety, quality, and governance. By enabling credentialed registered nurses to deliver protocolised, evidence-based assessment and treatment within defined clinical guidelines, the  model reduces delays to meaningful treatment, improves patient flow, and strengthens workforce capability without increasing staffing numbers. This approach aligns with contemporary health system priorities to optimise existing workforce capability and deliver  care in the most efficient and sustainable way. Successful implementation required a supportive organsational environment, including strong executive sponsorship, endorsement through established clinical governance structures, and alignment with legislative  and professional frameworks governing medicines and scope of practice. Clear Health Management Protocols, defined escalation pathways, and structured credentialing ensured patient safety and clinical accountability. Interdisciplinary engagement, including  collaboration with medical officers, nurse practitioners and senior leadership, was essential to build trust, clarify role boundaries, and support integration into existing clinical frameworks.

Disciplined implementation, supported by education, supervision,  and ongoing evaluation, enabled safe and consistent adoption of this model. Key lessons learned included the importance of early and sustained stakeholder engagement, particularly from senior medical and nursing leadership, to ensure shared understanding of  scope, governance, and escalation processes. Standartised education and credentialing were critical to ensure clinician confidence and consistency of practice. The project also highlighted the need for robust data collection systems to measure clinical, operational,  and workforce outcomes over time.

Limitations included initial time and resources required to develop protocols, credential staff, and embed governance processes, as well as variability in readiness across sites depending on workforce experience, leadership,  and support, and local operational pressures. Ongoing evaluation is required to quantify long term system impact, including effect on patient outcomes, workforce retention, and service efficiency. The EP-RN model supports Metro South’s strategic objectives  by optimising scope of practice, improving patient flow, enhancing workforce sustainability, and enabling scalable innovation across services. With standardized credentialing and protocolised clinical guidelines, the model has strong potential for implementation across emergency departments, urgent care centres, minor injury and illness clinics, where access to timely medical assessment may be limited. This model is also applicable to community based urgent care pathways and satellite hospitals, supporting equitable  access to safe, timely care across Queensland Health.

The next phase includes broader scale-up across additional facilities, refinement of education and credentialing frameworks, and integration into workforce and service planning. Longitudinal evaluation  will measure clinical outcomes, patient experience, workforce satisfaction, and system efficiency to inform continuous improvement. Establishing a standardized statewide governance and credentialing framework will support consistency and enable safe expansion.  This work will provide the evidence base required to support sustainable statewide adoption and position the EP-RN model as a key component of Queensland Health’s future workforce strategy.

References

ED Protocolised Care Project