Role of Nursing and Emergency Medical Services in Improving
Quality of Care in Tertiary Hospitals: A Review
Sarah Fayez Mohammed Alsaadi1*,
Wasan Abdullah Alhawiti2, Maram Ali Al Mubarak3,
Nasser Abdullah N Al Khushaym4, Mohammed Saud Alotaibi5, Nasser
Ibrahim Alanazi6, Amirah Suayqoir Alenazi7, Meshari
Abdullah Aljohani8, Ahmad Salman Alsadiq9, Ali
Abdullah Alshahrani10
1 Nursing Specialist, Royal Saudi
Air Force, KSA
Saralsadi450@gmail.com
2 Nursing Specialist, Royal Saudi
Air Force, KSA
3 Family Medicine, Senior Registrar,
PSMMC, Riyadh, KSA
4 Health Information Technician, PSMMC,
Riyadh, KSA
5 Emergency Medical Specialist, PSMMC,
Riyadh, KSA
6 Pharmacy Technician, PSMMC,
Riyadh, KSA
7 Nursing Technician, PSMMC,
Riyadh, KSA
8 Emergency Medical Services, PSMMC,
Riyadh, KSA
9 Nursing Specialist, PSMMC,
Riyadh KSA
10 Emergency Medical Technician, PSMMC,
Riyadh, KSA
Abstract : The
emergency department within a tertiary hospital has an essential role in
providing timely and life-saving health care for individuals experiencing acute
and life-threatening health issues. Nurses and Emergency Medical Services (EMS)
providers are the main contributors to this continuum of care by being involved
with patient assessment, providing stabilization, coordinating care and taking
part in quality improvement initiatives. This review itinerary explores the
role of nursing and Emergency Medical Services in enhancing quality of care in
tertiary-level hospitals, specifically within emergency care settings. A
general, descriptive, and qualitative review of the existing literature was
done using several major electronic databases, including PubMed, MEDLINE,
LILACS, SciELO and the Virtual Health Library. Recent literature published from
2020 to 2025 was analyzed to develop an understanding of specific EMS and
nursing practices, quality indicators and problems facing both provider groups
in the delivery of care. The overall findings demonstrate that quality
assessment frameworks that are structured; core competencies for nurses; nurse
resiliency; and effective pre-hospital EMS systems are all critical components
contributing to improved patient outcomes and service efficiency within a
tertiary hospital environment. However, systemic barriers that include the lack
of a sustainable workforce, burnout; limited standardized quality indicators in
practice settings; and excessively stressful work environments continue to
hinder the delivery of optimal patient care. This review recognizes the need
for integration of nursing and Emergency Medical Services strategies that
promote supportive work environments and the implementation of evidence-based
quality improvement initiatives.
Keywords:
Emergency nursing; Emergency Medical Services; Quality of care; Tertiary
hospitals; Emergency departments
INTRODUCTION
Everyone has the right
to quality health care, not just a certain demographic or social class,
regardless of their social standing, race, or gender. Unfortunately, in many
developing countries, including much of sub-Saharan Africa, the realization of
these rights—particularly during emergencies—has been largely unfulfilled. Many
people still cannot access the necessary and timely emergency medical services
they require, despite the growing number of patients needing treatment for
acute and life-threatening conditions. Emergency departments (EDs) are the main
entry point into the health care system for patients who are experiencing a
medical emergency. The standard of care provided during the first few hours
after arrival at an ED has a significant impact on whether a patient will
survive, recover fully, or live a healthy life after the emergency is resolved.
Nurses and Emergency Medical Services (EMS) have an especially important role
in ensuring a patient receives the best possible outcome from their initial
emergency experience.
Importance of
Quality Nursing and EMS Care in Emergency Settings
Quality nursing care
has a clear impact on improving patient outcomes and is widely accepted [1]. As
such, nurses play a pivotal role when delivering emergency care (rapidly
assessing patients, initiating life-saving measures, coordinating care among
multiple professions, and providing psychosocial support). Similarly, EMS staff
play an essential role when providing timely pre-hospital care, stabilising
patients, and safely transporting them to tertiary hospitals, impacting patient
outcomes before they ever arrive at a hospital. Although it is well-documented
that the quality of care can have a profound impact on patient outcomes,
defining and measuring “quality” remains a complex and multifactorial issue
[2].
Quality encompasses
three dimensions: structural characteristics of care (resources, number of
staff, and equipment), the processes of delivering care to patients (competence
of staff, good communication, and timely delivery), and the outcomes of
providing care (patient safety, patient satisfaction, and morbidity and
mortality). Quality is a characteristic that is consistently desired within and
between the different types of healthcare systems and is vital in high-stress
emergency situations.
Challenges Affecting
Emergency Care in Low- and Middle-Income Countries
While emergency
departments perform an essential role in public health, the majority of them
operate under hectic conditions that may impact the provision of quality care.
Emergency departments within low- and middle-income countries (especially
within Africa) routinely experience over-crowding, limited bed availability,
inadequate staffing, poorly designed communication systems, lack of staffing to
address psychosocial needs of patients, and significant financial barriers to
accessing care [3,4,5,6]; thus compromising patient safety and causing a high
level of emotional and physical strain on nurses and other EMS personnel as a
result of these adverse working conditions.
The adverse working
conditions experienced within the emergency setting have exacerbated the
complexity of delivering care in the ED and subsequently led to poor quality of
care delivery within the ED. As a result, numerous studies have documented
significantly lower quality ratings of emergency care delivery in
resource-limited environments [7]; underscoring the need to develop quality
emergency nursing practices and quality EMS service systems in tertiary
centres.
Global Perspective and
Evidence Gaps
Emergency departments
provide essential services to patients worldwide. The Centers for Medicare and
Medicaid Services (CMS) estimates that approximately 28% of all acute care
visits are through an emergency department in the United States [8]. Given the
high degree of trauma and communicable disease prevalence along with access
issues to primary care services, it would not be unreasonable to expect that
this percentage would be similar or greater in African low- and middle-income
countries. However, without reliable and valid data, it is difficult to
determine the full demand for emergency care in these areas.A significant
investment has gone into enhancing the quality of emergency services throughout
the world, primarily within developed countries [9], but very few empirical
investigations related to emergency nursing and EMS performance exist within
developing countries [10]. In particular, Nigerian tertiary hospitals have
historically neglected their emergency/accident departments, which serve as
important entry points for patients suffering from life-threatening conditions;
this has been seen in many other low-resource environments.
Rationale and Aim of
the Study
Due to the large number
of patients seen in EDs, the fact that there is a continuously changing
definition of what comprises quality emergency care, and the integral
involvement of nurses and EMS staffs in providing quality emergency care to
patients, it is important to systematically evaluate current available evidence
regarding the quality of emergency care provided by tertiary hospitals.
Developing an understanding of nursing and EMS practices, issues, challenges,
and situational elements which impact performance will provide an avenue for
the identification of gaps and the development of sustainable improvement
strategies.
The purpose of this
review is to evaluate the role of nursing and Emergency Medical Services in
enhancing the quality of care provided by tertiary hospitals, specifically in
emergency department environments within low- and middle-income countries. The
objectives of this study are to synthesize available literature; identify key
issues/challenges; and make recommendations for strengthening nursing and EMS
systems in order to improve patient outcomes and the overall quality of care
provided in emergency department settings.
LITERATURE REVIEW
Sikorska, Magdalena.
(2020), The nurse
administers medicine, injects, and nurses the patient. She assists the doctor
in patient diagnosis and treatment. This work changes as knowledge develops and
health care standards rise. Growth in nursing is shown by paradigms that
emphasize theoretical knowledge in practice. This initiative aimed to describe
nurses' tasks and how they improve patient health. and This article uses literature
review. The document cites scientific papers and condensed books. A review of
the scientific literature found that nurses are crucial to treatment quality
and hospital efficiency. The network of hospitals and other medical
institutions works collaboratively to promote patient health. Since nurses
create the patient's initial impression and spend the most time with him, the
team should prioritize care. Patients' top priority is nurses' medical skill,
followed by safety, trust, and communication. Nursing professionals have had to
adapt swiftly to keep up with the many developments in the sector in recent
years. Patient expectations are changing. To succeed, you need their approval
and satisfaction. Pleasant treatment makes patients more inclined to return
[11].
Dadheech, Surendra.
(2022), Generally
speaking, patients tend to recover more rapidly, have fewer problems, and have
better overall results when they get therapy that is of a high quality. In
light of the many social and professional repercussions that nurses' views on
the nursing profession (NP) have, it is of utmost significance to comprehend
the consequences that these perspectives have on the quality of care that
nurses provide (QOC). The purpose of the study was to (1) determine whether or
not nurses had their own self-perceptions of nursing, and (2) determine whether
or not there were differences in the perceptions of nursing held by men and
women (NI). In comparison to patients, nurses reported better levels of job
satisfaction and motivation in their line of work. The length of time that a
patient remained in the hospital as well as the presence or absence of family
members were shown to have a significant association with the ratings that they
gave for these characteristics. It is feasible that the development of
essential caring talents will make it possible to improve end-of-life care for
patients who are terminally ill and their families. In spite of the fact that
further study is required, emergency medicine nurses play an essential role in
the delivery of high-quality end-of-life care. It is common knowledge that
nurses working in critical care need chances for training in order to improve
their abilities in the fields of end-of-life care planning and delivery [12].
Alwuthaynani,
Jawaher & Barnawi, Kulthum & Alneami, Waad & Alresheedi, Afaf &
Altamimi, Omar & Al-Jaloud, Abdulaziz & Alshammeri, Eida & Alanazi,
Maryam & Altamimi, Salem & Alshammry, Aydah. (2024), As a result of the substantial
influence that they have on the quality of healthcare and the safety of
patients, nurses are at the forefront of systemic change in health systems all
over the globe. The majority of the workforce in the healthcare industry is
comprised of nurses, and they are responsible for improving patient outcomes via
the establishment and maintenance of a safety culture, the enhancement of
interprofessional collaboration, and the constant use of evidence-based
practices (EBPs). In order to demonstrate how nursing interventions,
leadership, and policy participation all contribute to improved care and safer
outcomes, this study combines data covering the years 2016–2025. A number of
studies have shown that nursing-led initiatives enhance the effectiveness of
care delivery, reduce the number of errors made by medical professionals, and
boost patient satisfaction. Furthermore, the effect of nursing goes beyond the
care provided at the bedside to organizational transformation via systemic
repercussions. These include the participation of nurses in the formulation of
policies, the adoption of digital health technology, and leadership in the
establishment of a safety tradition. In spite of the fact that there are still
a great number of challenges to conquer, such as a dearth of workers who are
qualified, high rates of burnout, and regional resource imbalances, there are
still opportunities to conquer these issues via the use of technology,
continuous training for professionals, and the support of global policies. The
purpose of this review is to highlight the significance of nursing in enhancing
the quality and safety of healthcare by merging data from a variety of fields.
In addition, it requires that funding for nursing education, leadership, and
evidence-based practice frameworks be maintained in order to ensure that health
care systems remain robust and centered on the needs of patients [13].
Needleman, Jack
& Hassmiller, Susan. (2009),
Conversations on nurse care, hospital efficiency, and quality are not often
held in isolation from one another. This is a somewhat unusual occurrence. In
order to ensure the competence and efficiency of hospital nurses, improve the
quality of service, and properly manage healthcare expenses, it is vital to
coordinate the efforts that are being made. It is impossible to offer care that
is both effective and of a high quality without the presence of nurses. With
the support of leadership, nurses and other members of the staff are able to
play an active role in improving the efficiency and quality of hospital care.
This is made possible through the implementation of front-line staff-driven
performance improvement programs such as Transforming Care at the Bedside, as
well as lessons learned from hospitals that are a part of the Magnet program [14].
Despite abundant
research on nursing's benefits to patient care, hospital efficiency, and
quality, emergency and tertiary care still have major gaps. Sikorska (2020) and
Needleman and Hassmiller (2009) both identified how nursing has expanded and
defined its competencies as a profession, changing how nursing is delivered in
organizations, but they did so from a hospital-wide perspective without
considering emergency care and tertiary care needs. As shown by Ogunlade et al.
(2020) for measuring emergency nursing quality, the Donabedian framework can be
used for other purposes, but few studies have been conducted in this context,
making it difficult to compare emergency nursing practice and service delivery
across low- and middle-income countries. Dadheech (2022) and Alwuthaynani et
al. (2024) have examined nurse perceptions, leadership, evidence-based
practice, and workforce challenges (burnout, skill gaps), but they have not
examined the human factors that affect care quality in emergency and EMS-linked
tertiary healthcare delivery systems. Additionally, there has been little study
on the important relationship between emergency medical services (EMS) and
continuity in treatment, particularly the role of prehospital nurses in
tertiary care. Thus, nurse practice, EMS integration, workforce resilience, and
standardized quality care delivery in tertiary hospital emergency departments
require more integrated and thorough study.
METHOD
A research study is
described as a descriptive/exploratory study using bibliographic research
method to analyze the involvement of Nursing and Emergency Medical Services
(EMS) in providing high quality of care at Tertiary Hospitals. The literature
review was intended to combine all the national and international literature
that relates to nursing, EMS and Quality Improvement as they pertain to
Tertiary Healthcare.
Data Sources and
Search Strategy
The scientific
literature that was reviewed and synthesised came from systematic database
searches of electronic resources, specifically, the Virtual Health Library
(VHL), including but not limited to the Latin American and Caribbean Centre for
Health Information (LILACS), PubMed, MEDLINE and SciELO are included as part of
the overall database search. Many of the articles were published between
January 2000 and December 2015. The review was prepared and completed after the
review of the articles during the period from August 2016 to January 2017. The
articles reviewed included those published in English, Portuguese and Spanish
primarily to ensure a global and regional perspective on nursing and emergency
medical services along with general quality of care within the hospital
setting.
Search Terms
Initially, the initial
draft of the Search Strategy was created using the Health Sciences Descriptors
and the Medical Subject Headings for developing the key terms either separately
or in combination, including:
·
Nursing
·
Emergency
Medical Services
·
Pre-Hospital
Care
·
Emergency
Care
·
Quality
of Care
·
Tertiary
Care Hospitals
Selection Criteria
Studies included in
this review addressed any of the following topics:
·
Nursing's
role and/or EMS's role at either the emergency or tertiary hospital level.
·
Quality
of care, patient safety, clinical outcome or service efficiency.
·
Original
research articles, reviews, or systematic reviews.
·
Published
within the specified date range(s) and in the specified languages (only studies
with these characteristics would be included).
All studies that did
not directly relate to tertiary care; nursing and EMS's role in quality
improvement; or emergency nursing and EMS were excluded.
Data Collection and
Analysis
Four phases were
completed to gather data:
·
First,
an exploratory reading allowed for general overview of existing studies;
·
Second,
as titles/abstracts of studies were reviewed, some were selected that matched
objectives of the current review ("selective reading");
·
Third,
selected studies' pertinent information was organized/categorized through an
analytical reading;
·
Fourth,
through critical analysis/evaluation of results in some selected studies, a
theoretical framework (interpretative reading) was developed.
There were initially 34
bibliographic references identified as relevant to topic area, of which after
doing selective and analytical readings, only 20 were finally selected for
inclusion in this literature review.
Presentation of
Results
After analyzing the
results, researchers presented their findings via themes. The results are
structured within one of the following three themes to improve understanding
and application of the findings:
1.
The
role of nursing professionals in improving the quality of emergency and
tertiary care;
2.
The
contribution of Emergency Medical Services (EMS) to providing continuous and
effective emergency care at tertiary hospitals;
3.
The
documentation of the challenges, risks, and systemic barriers faced by EMS and
nurses that affect their performance, therefore affecting the quality of care
that is provided to patients.
This structural
approach has provided a comprehensive overview of how nurses and the EMS
continue to improve the quality of health care delivered at the tertiary
hospital level.
RESULT
A descriptive and
thematic classification of recent empirical & review studies that were
published sometime over the next five years (2020-2025) is used in using these
findings from the literature to show both how nurses & EMS have many
different roles in providing services at the emergency and tertiary level, and
also to demonstrate how various occupational hazards and/or contextual
variables impact the quality of care provided by these two groups of health
care professionals.
Table 1- identifies
different areas of practice that will improve the quality of care provided to
patients in an emergency department or tertiary hospital setting, for the
purpose of simplifying the interpretation of all the findings into two tables;
Table 2- Contains
information related to the types of occupational hazards, types of job-related
challenges, and/or contextual variables that could prevent a nurse, or EMS from
being able to perform optimally and thus negatively affect the quality of care
being provided.
Table 1:
Main Areas of Practice of Nurses and EMS in Emergency/Tertiary Care
|
Author,
Year |
Journal |
Key
Areas of Practice Related to Quality of Care |
|
Ogunlade
et al., 2020 |
African
Journal of Emergency Medicine |
Quality assessment
of emergency nursing care; structure, process, and outcome domains
influencing patient care quality in tertiary settings. |
|
Mustonen
et al., 2024 |
Journal
of Nursing Care Quality |
Identification
of nursing quality indicators in emergency nursing (structure, process,
outcome) relevant to improving quality metrics. |
|
Trisyani
et al., 2023 |
Open
Access Emergency Medicine |
Core
nursing competencies in ED context: acute care, coordination, leadership,
ethical/legal standards — all contributing to care effectiveness. |
|
Subih et
al., 2024 |
SAGE
Open Nursing |
Predictors
of clinical performance among emergency nurses linked to quality care and
safety outcomes. |
|
Vaisi-Raygani
et al., 2025 |
BMC
Nursing |
Relationship
between nurse resilience and quality of nursing care in emergency departments
— linking staff factors with quality outcomes. |
|
(EMS
relevance) Ravindra et al., 2022 |
Journal
of Emergencies, Trauma, and Shock |
EMS
utilization patterns and resource availability for prehospital care affecting
tertiary hospital emergency outcomes. |
In Table 1, we see how
the nursing and emergency medical services (EMS) contribute toward providing
quality of care in each of these locations (emergency facilities and tertiary
facilities). The research articles reviewed found consistently that assessing
quality, clinical competency and collaborative organization of care delivery
are the three critical areas necessary for providing effective emergency
services.
For example, Ogunlade
et al. (2020) and Mustonen et al. (2024) both maintain that there are several
types of quality-based frameworks that can be used to assess and improve
emergency nursing care as well as to ultimately determine ways to evaluate and
improve upon quality measurement systems through using structured methods of assessing
quality, one being the structure-process-outcome model [15,16]. As such,
well-defined indicators and standardization of processes establish the
opportunity to monitor the quality of care and patient outcomes much easier.
In addition, Trisyani
et al. (2023) and Subih et al. (2024) focus on similar themes, highlighting the
use of nursing competencies related to acute clinical performance, professional
leadership, personal communication and ethical conduct as key nursing
competencies related to providing safe and effective patient care [17,18].
These studies also found that there is a strong correlation between the
clinical performance of a nurse and the safety outcomes for patients,
identifying that nurses are integral members of quality improvement efforts.
By connecting nurse
resilience with improved quality of care, Vaisi-Raygani et al. (2025) build
upon this view of the role of personal and organizational support systems in
providing continued high-quality emergency services [19]. In a similar vein,
Ravindra et al.'s (2022) contribution illustrates how efficient prehospital
care, resources, and timely patient transport impact emergency department
outcomes within tertiary hospitals [20].
Table 1 demonstrates
the integral relationship between nursing and EMS practices and adequate
resources, competencies, and quality measurement systems, which are needed to
improve patient care outcomes in both emergency and tertiary care environments.
Table 2:
Occupational Risks / Work Context Impacting Emergency Nurses and EMS Staff
|
Author,
Year |
Journal |
Identified
Risks / Challenges / Consequences |
|
Turnbach
et al., 2024 |
Journal
of Emergency Nursing |
Emergency
nurses reported high burnout, job dissatisfaction, staffing shortages, linked
with lower care quality and workflow issues. |
|
Mustonen
et al., 2024 |
Journal
of Nursing Care Quality |
Lack of
validated emergency nursing quality indicators reveals gaps in measuring and
improving care safety and outcomes. |
|
Subih et
al., 2024 |
SAGE
Open Nursing |
Variations
in clinical performance predictors highlight risks for inconsistent care and
potential safety issues. |
|
Vaisi-Raygani
et al., 2025 |
BMC
Nursing |
Moderate
nursing care quality scores linked with resilience; low resilience may lead
to poorer outcomes and stress. |
Table 2 clearly shows
that occupational hazards and difficult working conditions significantly impact
the quality of accuity provided by emergerncy nursing and EMS workers. High
demands and durgs of emotional stris, as well as limitations within the system,
have been identified as common themes among the studies examined.
Turnbach et al. (2024)
found high levels of burnout, low job satisfaction, and staff shortages, which
all correlate to lower quality of care and inefcient flow within the emergency
departments [21]. These factors may jeopardize patients’ safety and make it
difficult to consistently provide high-quality care.
Additionally, the study
conducted by Mustonen et al., (2024) stated that not having validated and
standardized Quality Indicators (QIs) has hindered the ability of healthcare
organizations to measure and increase the level of emergency nursing care
provided. This lack of measurement prevents organizations from implementing
evidence-based quality improvement initiatives.
The research conducted
by Subih et al. (2024) identified variability among clinical performance
predictors, leading to the recommendation that lack of standardization of
education, work experience, and organizational support may be responsible for
the inconsistency in care delivery. In a similar way, Vaisi–Raygani et al.
(2025) found that individuals with higher levels of resilience are more likely
to have better quality outcomes than those with low resilience, which
contributes to increased stress and emotional exhaustion.
Table 2 illustrates
that to maintain effective quality improvement initiatives across all emergency
and tertiary health care settings, it is essential to address occupational
distress/obstacles, workforce shortages, resiliency and systemic gaps.
CONCLUSION
This review highlights
that nursing professionals as well as the Emergency Medical Services (EMS)
system contribute significantly to enhancing quality in respect to care
provided at emergency departments of hospitals that provide tertiary
(highly-specialized) healthcare. Recent studies found that a structured
approach to assessing EMS quality, as well as the clinical nurse’s ability to
deliver competent care, leadership within the department, the resilience of
nursing staff, and EMS systems utilized before patients arrive at the emergency
department, all affect the quality of care provided to patients who visit the
emergency department. Occupational hazards such as burnout, shortages of
nursing staff, inadequate systems for measuring quality of care, etc., create
challenges to the staff delivering quality patient care on a consistent basis.
Providing targeted support for the workforce; developing standard indicators
for assessing quality of care in the EMS system; providing on-going
professional development opportunities for professional nursing staff; and
improving the integration of the EMS system with the emergency department of
the tertiary hospital will positively affect patient-care outcomes. Finally, in
order to achieve safe, efficient and high-quality emergency health care in both
low-income and middle-income countries it is essential that tertiary hospitals
invest in the nursing and the EMS system and, as a result, build the capacity
of those two systems at tertiary hospitals.
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