Exploring the implementation of nurses’ advanced competencies in emergency departments: a scoping review

Abstract

Emergency department (ED) overcrowding is a critical issue that compromises patient safety, prolongs waiting times, and increases staff workload. Contributing factors include insufficient primary–community care integration, staffing shortages, operational inefficiencies, and an ageing population with complex chronic conditions. These pressures are further exacerbated during disasters and are expected to worsen with the rising frequency of climate-related crises. Task shifting and the expansion of advanced nursing roles have been proposed as strategies to mitigate overcrowding; however, their adoption remains limited. This scoping review aims to map the existing evidence on advanced nursing practice in EDs, describing roles, outcomes, facilitators, and barriers. Following Joanna Briggs Institute methodology and PRISMA-ScR guidelines, we searched PubMed, Embase, and Scopus, without date restrictions, for original studies from high-income countries in which nurses autonomously performed functions beyond standard care. Of 3,029 records, 105 met the inclusion criteria, with most studies originating from Canada, Australia, and the USA. Three role categories were identified: (1) autonomous management of specific presentations (“See and treat”); (2) nurse-led patient flow management; and (3) triage nurse ordering, which allows nurses to order investigations or initiate treatment for predefined conditions at triage. Across settings, these models demonstrated comparable quality of care, clinical effectiveness, and patient and staff satisfaction to physician-led management, while often reducing waiting times and healthcare costs. Despite evidence being heterogeneous and largely single center, the findings support the safety and effectiveness of advanced nursing roles in EDs. This review highlights current research gaps and provides a foundation for designing multicenter trials and pilot programs to optimize the integration of advanced nursing competencies into ED systems.

Introduction

Emergency department (ED) overcrowding has long been recognized as a significant issue, compromising patient safety and privacy, prolonging waiting times, and increasing staff workload and stress [1]. Multiple causes have been identified, ranging from seasonal variability due to illnesses such as influenza or exceptional situations like the COVID-19 pandemic [2], to structural factors. These structural issues include poorly organized primary care, limited access to community-based diagnostic services [3], insufficient staffing, and shortages of healthcare workers (HCWs) [4], further compounded by a concerning workforce dropout rate driven by stress and burnout [5]. Additional contributing factors include delays in receiving test results, slow disposition decisions, inadequate availability of hospital admission beds, and inefficient discharge planning [6].

Furthermore, population aging and the rising prevalence of chronic non-communicable diseases (NCDs), particularly in high-income countries, have increased the demand for urgent and complex care, especially among older adults [7]. This challenge is aggravated by the high volume of unnecessary, non-urgent visits and the frequent use of emergency services by so-called “frequent flyer” patients, leading to inappropriate utilization of emergency care resources [6].

As demonstrated in the aftermath of Hurricane Katrina, ED overcrowding becomes particularly acute during disasters, as emergency services are at the forefront of receiving, managing, and treating victims and evacuees [8]. Given that disasters caused by natural hazards, such as cyclones, hurricanes, flooding, and landslides, are projected to increase in frequency and intensity due to global warming in the coming decades [9], disaster preparedness and management strategies must explicitly address ED overcrowding. The WHO Global Health Workforce 2030 document emphasizes the importance of optimizing the roles of mid-level healthcare professionals, such as nurses, by avoiding underutilization of their skills and reconsidering professional responsibilities and workloads [10].

Several countries have developed initiatives in this direction. In Commonwealth nations (UK, Australia, Canada) and the USA, the role of an advanced practice nurse (APN) is well established. APNs undergo additional university-level training, enabling them to independently request and interpret diagnostic and laboratory tests or manage so-called ‘minor’ cases, such as small traumas or uncomplicated clinical presentations (e.g., upper respiratory tract infections or urinary tract infections) [11]. In these countries, implementing APNs has been shown to reduce waiting times, improve patient satisfaction, and lower healthcare costs [12–14]. Integrating such roles into emergency care enables medical staff to focus on more complex cases, thereby improving access to timely, high-quality care and reducing overall ED overcrowding [15].

However, these practices are not widely adopted. For example, in Italy, despite an estimated shortage of approximately 5,000 physicians in EDs [16], only a few isolated task-shifting initiatives and APN implementations have been undertaken [17–22]. Broader adoption of this approach is critical for enhancing both access to and quality of healthcare services, and to tackling ED overcrowding.

This research addresses this need. Given the broad and exploratory nature of the aim, a scoping review was conducted to systematically collect and categorize the existing evidence on the role of APNs in EDs, thereby providing a robust foundation for planning and implementing such models in countries where they are not yet established. A further objective was to evaluate the reported outcomes and identify barriers and facilitators influencing a widespread adoption of this strategy, especially in settings where few initiatives have been implemented to date.

Review questions

• What scientific evidence exists regarding the role of advanced nursing staff in EDs?

• In which clinical scenarios are advanced nursing personnel typically involved?

• What are the outcomes related to quality of care, effectiveness, and patient satisfaction when an advanced nursing role is implemented in EDs?

• What are the main barriers to the implementation of APNs in EDs?

Methodology

This scoping review was conducted in accordance with the recommendations of the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis, considering the PCC framework, where P stands for ‘participants’, C for ‘concept’, and C for ‘context’ [23], and following the guidance for large scoping reviews [24].

It was reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and its extension for Scoping Reviews (PRISMA-ScR) checklist [25]. The study protocol was registered in the Open Science Framework (OSF) under the Digital Object Identifier (DOI) 10.17605/OSF.IO/ZHQW6. Consistent with the scoping review methodology, no risk-of-bias or quality assessment was performed [26].

Inclusion criteria

Considering the PCC framework, the following inclusion and exclusion criteria were considered:

PCC elements	Definition
Population	Advanced practice nurses (APNs)—nurses who have undergone additional graduate education to acquire an advanced knowledge base, complex decision-making skills, and clinical competencies tailored for advanced nursing practice (ANP). These characteristics are influenced by the specific context in which they are authorized to practice [27]
Concept	Advanced nursing practice (ANP)—field of nursing that extends and expands the boundaries of nursing’s scope of practice, contributes to nursing knowledge, and promotes advancement of the profession, characterized by the integration and application of a broad range of theoretical and evidence-based knowledge that occurs as part of graduate nursing education [27]
Context	Emergency departments (EDs) in high-income countries

Type of source

This scoping review included original studies published in peer-reviewed journals and indexed in scientific databases, regardless of their methodological approach. Editorials, viewpoints, and opinion papers were not included.

Search strategy

A search string was developed by combining keywords related to “nurses” with terms indicating advanced roles they may undertake (“See and treat”, “task shifting”, “task sharing”, “fast track”, “minor injuries”) in “emergency departments” using Boolean operators. The search was conducted in May 2025 across four databases: Embase, PubMed, Scopus, and Web of Science (Appendix 1). In addition, reference lists of relevant articles were manually screened to identify studies not indexed in the selected databases. No temporal restrictions were applied. Only manuscripts available in English, Italian, or German were considered.

Study selection

All retrieved records were uploaded to the Rayyan Systematic Review Literature tool [28], where duplicates were removed. Two reviewers (FR, LCA) independently screened titles and abstracts according to the predefined inclusion and exclusion criteria. Full texts of potentially eligible articles were then assessed by both reviewers. Discrepancies were resolved through discussion and consensus with the co-investigators. The included studies were subsequently categorized according to the advanced nursing role described.

Data extraction

A data extraction form was developed a priori and used to systematically collect relevant information from the selected studies. Extracted data included study context, roles and tasks performed by nurses, reported outcomes, and recommendations for improving or expanding the implementation of these roles. Additional details on specific tasks performed by nurses for defined clinical presentations were also collected. Where available, information on barriers and facilitators to implementation was recorded. Data extraction was carried out by the first author (FR) and verified by a second reviewer (LCA). The findings were organized into three main categories:

(i) Quality of care: clinical outcomes directly linked to the advanced practice and nurses’ clinical decision-making, including the accuracy and quality of diagnostic and therapeutic actions (e.g., radiograph interpretation, symptom management, clinical documentation), and resulting patient health outcomes.

(ii) Effectiveness: the impact of nurses' advanced competencies on the operational efficiency of healthcare services in emergency settings, such as reductions in waiting times, improved patient flow, faster triage and treatment initiation, and decreased dropout rates.

(iii) Satisfaction: measures of satisfaction among patients and healthcare providers regarding nurse-led interventions or expanded nursing roles, including perceived care quality and acceptance of new organizational models.

Results

Screening process

A total of 3,081 records were identified through database searches. After removing duplicates (n = 923), 2,158 articles remained for relevance screening. Of these, 1,933 were excluded based on the review of titles and abstracts, leaving 225 studies for further assessment. Seven additional records were excluded due to unretrievable full texts, resulting in 218 reports subjected to full-text screening. This process led to the exclusion of 110 articles, with 108 ultimately included in the study. (Fig. 1).

Fig. 1.

Identification of studies.

Adapted from PRISMA extension for scoping reviews (PRISMA-ScR). From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71

Macro-areas of advanced roles identified

The final analysis of the articles revealed three primary categories of advanced nursing roles:

(i) Autonomous clinical patient management: Studies in this category examined nurses independently managing patients with specific clinical presentations in the ED, adopting a nurse-led “See and treat” (S&T) approach.

(ii) Advanced triage or “triage nurse ordering” (TNO): In this category, nurses were granted autonomy to request laboratory or radiologic tests or administer treatments during triage for predefined clinical cases.

(iii) Flow management: Publications in this category described the nurse’s role as a “flow manager” (FM), also referred to as a flow coordinator, navigator, greeter nurse, or journey coordinator. In this capacity, nurses managed patient flow within the ED, coordinating processes from triage to either discharge or admission.

“See and treat” study results

Overview of the retrieved articles

A total of 65 studies analyzed the role of nurses in the S&T approach [29–93]. Most were conducted in the UK (n = 29) [29–35, 37, 43, 47, 49, 50, 52, 53, 55, 64, 67–70, 72, 73, 75, 76, 79–81, 81, 88, 89] and Australia (n = 16) [40, 42, 46, 51, 60–62, 65, 66, 71, 77, 78, 82, 86, 87, 90] (Fig. 2). The earliest studies appeared in the 1990 s, with publication numbers increasing in the 2000 s and peaking in 2012. Most articles were published in the past decade (Fig. 3), and the majority focused on adult populations, with only four addressing pediatric patients [48, 49, 74, 91]. All studies were conducted in hospitals handling an average of 10,000–80,000 annual visits, with a few exceptions involving hospitals managing more than 100,000 visits annually. Settings included tertiary hospitals (n = 8) [38, 49, 61, 64, 65, 74, 89, 92], metropolitan hospitals (n = 17) [37, 40, 43, 46, 54, 55, 60, 62, 66, 68, 69, 77, 80, 81, 83, 84, 86], and university hospitals (n = 7) [36, 44, 48, 51, 74, 85, 90]. Study designs predominantly comprised retrospective and prospective cohort studies (n = 30) [31, 33–40, 42, 52, 54, 59, 61, 63, 64, 66–68, 71, 72, 75, 77, 81, 82, 84, 86, 88, 89, 92].

Fig. 2.

Number of retrieved articles per country

Fig. 3.

Number of retrieved articles per year

Focus

Most studies focused on emergency nurse practitioners (ENPs), nurses with specialized training to perform advanced tasks and extensive ED experience [30, 31, 38–40, 42, 44–46, 48, 51, 54–56, 58, 60, 62–64, 66, 75–78, 80, 83, 85–87, 92]. ENP training programs typically included wound suturing for minor injuries, radiographic interpretation, cast application, and therapy administration (e.g., pain management). APNs were also analyzed. These professionals practice at an advanced level of nursing, having completed a degree in "advanced practice". Both roles require additional training and experience, enabling competencies in interpreting clinical signs and symptoms, analyzing diagnostic tests, prescribing medications, and performing specific procedures as permitted by legislation. Some studies also examined nurses specializing in cardiology with advanced competencies, such as managing atypical chest pain [59, 63, 78].

The clinical presentations addressed in the publications were uniformly “minor” conditions, non-critical and non-life-threatening. Examples include extremity trauma [29, 30, 32, 44, 45, 49, 53, 55, 64], shoulder dislocations [91], acute hip and foot injuries [44, 45], minor wounds [33, 51, 57, 66, 69, 82, 86], mild burns [85, 86, 92], otitis [58, 74], mild asthma [74, 92], uncomplicated fever [48, 92], urinary retention [65, 92], vaginal infections [92],, vomiting and diarrhea [48, 74], urticaria [74], chest pain [59, 78], mild allergic reactions [74, 86], dental pain [77], and renal colic [37].

Outcomes

Quality of care

Three randomized controlled trials (RCTs) compared nurse-led management of minor trauma with that of junior doctors or trainees, finding no statistically significant differences in prescribing appropriateness or the interpretation of standard radiological examination [43, 45, 80]. Similar results were reported in a study on minor injuries and illnesses [85]. In three further prospective studies, the sensitivity of nurse practitioners in identifying limb injury radiographs compared to radiologist interpretation ranged from 91 to 96%, while specificity ranged from 78 to 87% [29, 30, 62]. Additionally, Roche et al. reported guideline adherence and diagnostic accuracy in ECG interpretation in 91% of cases [78]. In the study by Sakr et al., nurses demonstrated greater accuracy in history taking and better adherence to guidelines than physicians [80]. Other studies noted that nurse practitioners' interpersonal skills often surpassed those of physicians, improving access to care [41], with comparable patient outcomes [32], and consistent referral and discharge decisions [53, 56]. In the RCT by McClellan et al., functional recovery from minor limb injuries managed by nurses was found to be non-inferior to physician-led care (Fig. 4 and Table 1) [69].

Fig. 4.

Main outcomes evaluated in the retrieved articles

Table 1.

Summary of the outcomes for the three advanced nursing practice roles

Advanced nursing practice role	Number of retrieved studies	Outcomes—quality of care	Outcomes—effectiveness	Outcomes—satisfaction
See and treat	65	Accurate history taking and strong guideline adherence	Shorter waits, treatment time, and total ED time	Stronger interpersonal communication; easier access
		X-ray ordering/interpretation and ECG reading comparable to physicians	Earlier analgesia administration	Clearer discharge and follow-up information
		Referral and discharge decisions broadly aligned with physicians	Improved patients’ flow, fewer left without being seen, and reduced overcrowding	More consistent counseling on medicines and side effects
		Functional recovery non-inferior to physician-managed care for comparable minor limb injuries	Lower reattendance; fewer unplanned visits to other providers
			Projected cost savings
Triage nurse ordering	25	No adverse events with nurse-initiated antiemetic/analgesic therapy	Earlier therapy administration improved throughput and expedited discharge, reducing admissions	Nurses viewed pain-delegation positively and aligned with their role
		Triage-ordered labs improved triage code accuracy and safety
		Ordering quality comparable to doctors; physicians more often ordered ultrasounds/urine tests	Fewer resources used REDUCED waits, LOS, and ED length of stay	High staff and users’ satisfaction after TNO implementation
Flow manager	18	Improved recognition of critical conditions at reception	Shorter LOS, door-to-provider times, and total ED time	Positive patient feedback; better understanding of discharge procedures
			Improved patients’ flow and overcrowding
		Enhanced patient management in the ED at discharge	Mixed effects on “left without being seen” (some reductions, others unchanged)
		Readmission rates comparable to standard discharge	Lower overall and labor costs; attendance increased in some settings	High staff satisfaction

ECG electrocardiogram, ED emergency department, LOS length of stay

Effectiveness

Seventeen studies reported shorter assessment waiting times under nurse-led management compared to physician-led care [34, 36, 42, 43, 51, 52, 54, 59–61, 63, 66, 74, 77, 79, 84, 90], while 2 studies found no significant differences [81, 85]. Cherry et al. observed that patients managed by nurses spent half the time in the ED compared with those managed by physicians [37], although another study reported no difference in total consultation time [43]. The same study also found that patients in nurse-led care received pain relief more quickly than those under physician-led management [37]. Feetham et al. reported lower reattendance rates among pediatric emergency nurse practitioner patients (1.75%) compared with senior and junior doctors in training (4.29% and 5.76%, respectively), although this difference diminished after adjusting for patient population differences [49].

Implementation of the S&T strategy improved waiting times for patients with minor conditions and for those on standard care pathways, thereby reducing overcrowding [40, 57, 72], and increased daily patient throughput while maintaining quality of care [84]. Three studies reported reduced abandonment rates [36, 52, 92], while another found that patients seen by nurses were more likely to receive a written discharge letter, information on equipment and medication side effects, and follow-up instructions [33]. One study also reported an overall decrease in unscheduled visits to another healthcare provider [87]. Finally, a cost analysis of implementing the S&T protocol for minor cases in an Italian first-level hospital projected annual savings exceeding €100,000/year [93].

Satisfaction

All studies assessing patient satisfaction reported high levels, particularly regarding privacy, information provision, and emotional and informational support [32–34, 60, 65, 67, 78, 80, 81, 84, 88–90, 92]. In an RCT by Cooper et al., patients managed by nurses expressed higher satisfaction than those under physician-led care [43]. Similarly, Dinh et al. found that 68% of patients rated nurse-led care as excellent, compared with 50% for medical management [46]. Byrne et al. also found that patients treated by ENPs reported significantly reduced health-related worry compared to those treated by physicians [33].

Staff generally supported the nurse-led role [47, 53], although challenges were noted when protocols were unclear [40, 70, 72, 77]. Clear protocols and defined roles were identified as essential for effective interprofessional communication and collaboration [64, 75], ensuring consistency in managing specific conditions [35, 70, 71]. McConnell et al. reported that nurses perceived their scope of activity as primarily determined by their competencies, influenced by patient preferences, protocols, nursing management directives, and prescribing authority [70].

To summarize, S&T models enabled nurses to autonomously manage minor, non-life-threatening conditions across diverse ED settings. Evidence from RCTs and cohort studies demonstrated safety and clinical quality comparable to physician-led care, with some studies reporting superior guideline adherence and communication skills among nurses. Implementation frequently reduced waiting times, improved patient flow, and, in some cases, lowered reattendance rates and healthcare costs. High patient satisfaction, particularly regarding information provision and interpersonal care, was consistently observed. Success was strongly linked to clear protocols and role definitions, which facilitated interprofessional collaboration and ensured consistent standards of care.

Triage nurse ordering study results

Overview of the retrieved articles

A total of 25 studies examined triage nurse ordering (TNO) roles [94–118]. Most were conducted in the USA (n = 9) [95, 108, 111–117] and in Europe (n = 8) [97, 103–107, 109, 110]. The publications spanned from 2010 to 2022, with the highest number published in 2020 and a notable increase between 2016 and 2020. Nineteen studies focused on adult populations [94–100, 102, 103, 105–107, 109, 112–115, 117, 118], while 6 addressed pediatric patients [101, 104, 108, 110, 111, 116]. Nearly half of the studies were conducted in EDs within tertiary hospitals (n = 10) [94, 95, 98, 102, 107, 109, 113, 116–118] with reported annual visits ranging from 44,000 to 66,000. Regarding study design, the majority were observational (n = 9) [96, 98, 101, 106, 108, 111–113, 117] or descriptive (n = 6) [95, 99, 105, 107, 114, 116].

Focus

Study foci varied. Eight articles examined therapy administration specifically at triage [98, 99, 101, 109–112, 115], while 15 focused on ordering laboratory tests [94–97, 100, 103–106, 108, 113, 114, 116–118]. One study addressed protocols for both therapy administration and diagnostic laboratory testing [102], and another used qualitative methods to explore nurses’ perceptions regarding the implementation of a pain management procedure [107].

Outcomes

Quality of care

Two studies evaluated therapy administration by TNO nurses for nausea or pain management, reporting no adverse events. Both studies noted an association between earlier therapy administration and improved patient throughput, as well as a higher likelihood of expedited discharge from the ED [98, 111]. Two additional studies highlighted the benefits of targeted pain management training and the use of care bundles in improving analgesia administration [107, 115]. Another study reported that laboratory tests ordered directly at triage improved the accuracy of triage code assignment, enhancing patient safety [96]. No significant differences were observed between doctors and nurses in triage-based ordering, although physicians ordered more ultrasounds and urine tests [100].

Effectiveness

Few studies reported a reduction in ED length of stay (LOS) [104, 105, 108, 118], particularly for patients with respiratory and trauma-related presentations [116], chest pain [113], and for those admitted compared with those discharged [102, 103, 106]. Standardized nurse protocols for blood sampling further reduced LOS in lower-priority cases [117]. The implementation of evidence-based protocols, such as the Ottawa Ankle Rules, allowed triage nurses to improve ED waiting times and LOS while reducing unnecessary ankle X-rays [94, 97]. Gautier et al. found that over 95% of X-rays ordered by nurses were deemed adequate by the medical team [104], while educational interventions improved adherence to guidelines for nurse-initiated X-ray requests [95]. Similarly, nurse-led steroid administration shortened time to treatment for pediatric asthma, subsequently lowering admission rates [99, 109, 110]. Moreover, nurse-initiated pathways reduce resource utilization; for example, gastroenteritis patients required less intravenous fluid and laboratory testing, and achieved faster discharge, compared with those managed through provider-initiated pathways [101].

Satisfaction

Patient and staff satisfaction was evaluated in a study by Hadorn et al., which found that ED nurses viewed a pain management delegation protocol positively. They noted its benefits in enhancing care quality and aligning with nursing roles, while also emphasizing the need for further knowledge development [107]. Other studies likewise reported high satisfaction levels among both doctors and nurses following the implementation of TNO roles [94, 102].

To summarize, TNO models demonstrated comparable quality of care to physician-led ordering, with no adverse events and high adherence to guidelines. Evidence indicated potential reductions in LOS, faster treatment initiation, and decreased resource use, particularly when supported by standardized protocols and targeted training. Both staff and patients generally reported high satisfaction, citing improved care quality and better alignment with nursing roles.

Flow manager study results

Overview of the retrieved articles

A total of 18 articles focused on the flow manager (FM) role [119–136]. Most were conducted in the USA (n = 7) [124, 126, 131–134, 136] and Australia (n = 5) [120, 122, 125, 127, 128]. The earliest studies date back to 2003, with a notable increase in publications after 2014. Seven studies were conducted in tertiary hospitals [119–121, 125, 126, 131, 132], with annual patient volumes ranging from 50,000 to 130,000. The methodologies included RCTs (n = 3) [121, 130, 133], cohort studies (n = 4) [119, 122, 125, 132], case studies (n = 8) [123, 124, 126–129, 131, 134], and one before-and-after study [120].

Focus

The FM role varied across studies, encompassing tasks such as ambulance off-loading, patient reception, waiting area management, and facilitating transitions from the ED to home discharge [119, 122, 125, 127, 128, 130]. In one study, the FM role was implemented only during peak patient inflow periods [122]. This variation was reflected in the diverse terminology used, including flow coordinator, greeter nurse, nurse navigator, patient flow coordinator, journey coordinator, emergency department ambulance off-load nurse (EDAOLN), and bypass rapid assessment triage flow. In all cases, an experienced nurse was dedicated to optimizing patient flow within the ED. Conditions managed by FM nurses included elderly patients with confusion or disorientation, and those presenting with chest pain, non-complicated trauma, stroke, dyspnea, suicidal ideation, severe pain, and infections.

Outcomes

Quality of care

The FM role has been shown to enhance patient management in the ED and at discharge [136]. Howard et al. reported that including an FM nurse at reception improved recognition of critical conditions and overall care quality [126]. In an RCT by Cosette et al., nurse-led discharge interventions showed no significant difference in readmission rates compared with controls [121]. Similarly, Lisby et al. found no significant differences in 30-day readmission rates for patients discharged home with nurse facilitation [130].

Effectiveness

All studies assessing effectiveness reported improvements in key indicators, including LOS and door-to-provider times, after implementing the FM role. La et al. demonstrated that increasing physician availability in triage, followed by adding an ENP, reduced LOS and assessment queues, highlighting the importance of clinical leadership in optimizing patient flow [129]. Similar reductions in LOS and waiting time were also noted in other studies [122–124, 131, 132, 135]. Chiu et al. found that the FM role improved the overcrowding index by facilitating patient movement, although it did not reduce the number of patients leaving without being seen [134]; however, other studies did report a reductions in this metric [131–133]. In contrast, Alsolamy et al. observed an increase in LOS, coinciding with higher patient volumes and admission rates, reflecting the challenge of balancing patient inflow with available resources [119]. Crilly et al. found that implementing an EDAOLN reduced overall healthcare costs [122], while two other studies reported increased ED attendances following FM role introduction [120, 133]. Finally, Fullbrook et al. conducted an economic analysis showing reduced labor costs due to time savings from the FM role [125].

Satisfaction

Studies assessing patient satisfaction reported favorable outcomes regarding the FM role. In an RCT conducted by Lisby et al., patient satisfaction was compared between those discharged under nurse-led management and those receiving standard discharges. While no statistically significant differences were observed in the perceived quality of the discharge process, a higher proportion of participants in the intervention group (59%) strongly or very strongly agreed that they were better informed about discharge procedures compared with the control group (47%) [130]. Similar findings were reported by Innes et al. [127]. Nurse satisfaction with the FM role was also evaluated. In the study by Murphy et al., satisfaction levels were measured before and after FM role implementation, with over 73% of nurses expressing satisfaction with the new role [132]. Similarly, Marino et al. reported higher satisfaction levels among nursing management during shifts that included the FM figure [131]. In another study, the FM role was initially perceived as a strain on triage resources; however, over time, nurses acknowledged that the early identification of clinical deterioration facilitated by this role contributed to increased satisfaction among the nursing staff [126].

Overall, FM roles generally improved patient flow, reducing LOS and door-to-provider times, with occasional cost savings. Variability in tasks and role definitions reflects adaptability, though outcomes may be influenced by patient volume and resource availability. Benefits also included positive patient satisfaction, particularly regarding discharge information, and high nurse satisfaction, especially as the role’s value in early clinical deterioration recognition became evident.

Barriers to APN implementation

A total of 39 articles identified various barriers hindering the implementation of ANP in EDs, which can be grouped into three main categories. Firstly, training barriers were frequently reported as significant obstacles to nurses acquiring the skills and knowledge required for advanced practice. These include insufficient access to specialized training programs, a lack of standardization in training approaches, and the absence of ongoing professional development opportunities [29, 31, 33, 38, 44, 77, 93, 111, 114, 115, 124]. Second, the absence of clear, shared protocols, particularly within multidisciplinary teams, emerged as a common barrier. A lack of standardized protocols can cause confusion and role overlap, leading to inefficiencies and potential errors in patient care. It can also hinder effective communication and coordination across disciplines [35, 37, 38, 53, 54, 67, 77, 80, 87, 89, 97, 101, 102, 114, 117, 136]. This includes insufficient systems for continuous supervision, monitoring, and corrective actions when errors occur [55, 80]. Third, few studies highlighted the need for robust professional policies and legal frameworks. Standardized policies are essential for clearly defining the scope, responsibilities, and legal boundaries of ANP roles. In their absence, ambiguity regarding duties and limitations may lead to potential legal and professional challenges [55, 64, 86, 104]. Additional barriers include resistance to expanding nursing roles, particularly from the medical profession [75], inadequate financial recognition for advanced competencies, increased clinical workload, and limited opportunities for career progression [82, 90, 97, 104, 112, 125, 128, 130].

Discussion

This literature review identified 108 articles examining ANP roles in EDs, grouped into three categories: “See and treat”, triage nurse ordering, and flow manager. Across diverse healthcare systems and ED contexts, ANP models consistently demonstrated safety, high quality of care, effective patient management, and high satisfaction among both healthcare staff and patients. In most studies, nurses-led models achieved outcomes comparable to physicians, with improvements in operational metrics such as time to provider, length of stay, as well as enhanced communication and information at discharge. Together, these findings support the effectiveness and safety of ANP-led interventions in the ED and their contribution to alleviating overcrowding.

These results are congruent with prior syntheses. Horvath et al.’s review reported improved waiting times, lower rates of leaving without being seen, and more efficient resource use, alongside gains in patient and staff satisfaction and organizational performance [137]. These improvements, however, are not limited to the ED, and over the past decade studies across various specialties and care settings have linked APN to positive patient outcomes. APNs have been shown to contribute to better outcomes for people with lung cancer by reducing unplanned cancer-related hospitalization [138] and to improve the well-being of individuals affected by intellectual disabilities and their families [139]. Their role has also been proven to be effective for patients with heart failure [140], dementia [141], asthma [142], or chronic kidney disease [143]. Studies have also examined APN in other settings. Laurant et al. analyzed APNs in primary care, finding that they can deliver care comparable to or better than general practitioners, with equal or better patient outcomes and higher patient satisfaction [144]. Similarly, a systematic review by Swan et al. reported comparable clinical outcomes and patient satisfaction levels between advanced practice nurses and physicians in primary care, with nurses delivering quality care at equal or lower costs [145]. Collectively, these findings suggest that the benefits of advanced nursing roles extend beyond the ED and reflect a broader, transferable set of competencies. The COVID-19 pandemic further accelerated the expansion of ANP [146, 147]. As in other disaster contexts, surges in healthcare needs highlighted the value of task shifting to trained non-physician clinicians to optimize available resources by empowering nurses and community health workers to perform tasks traditionally reserved for physicians and to preserve timely access to care [148]. In such scenarios, ANPs have been pivotal not only as key frontline providers during disaster response, but also as central actors in preparedness and mitigation, underscoring their role in resilient health-system design.[149].

The increasing frequency of disasters and emergencies, coupled with unfavorable future projections, strengthens the urgent need for further promoting and implementing APNs. The effectiveness of ANP roles is however shaped by the structural characteristics of healthcare systems, clinical training pathways, ED organization, and legal or regulatory frameworks, highlighted by the heterogeneity observed in the included studies. These factors influence both the external validity of our findings and, coupled with the several barriers highlighted in the study, the feasibility of a single APN model implementation. In particular, regulatory scope and liability frameworks determine prescriptive authority, ordering rights, and requirements for collaboration or supervision; where scope is constrained, the benefits of APNs are often attenuated. Education and credentialing models also matter: standardized, graduate-level preparation and role-specific competencies (including imaging interpretation, wound management, and protocolized prescribing) support safe autonomy, whereas variable or ad hoc training tends to narrow responsibilities and dampen impact. EDs organization, clinical pathways, and financing/workforce arrangements similarly determine where and which APNs add the most value and whether their efficiency gains can be sustained over time.

These dynamics are evident in country exemplars. In the USA, ANP scope varies by state, ranging from full practice authority to restrictive collaborative agreements, with implications for both clinical reach and financial sustainability [150]. In the UK, emergency nurse practitioners (ENPs) operate within established service models, yet national regulation by the Nursing and Midwifery Council does not centrally define the role; scope and credentialing are employer determined, creating local variability [151]. In Australia, nationally standardized education and registration—typically a master’s degree with advanced clinical competencies—together with strong primary–secondary care integration, have supported the adoption of ANP roles in EDs [152]. In contrast, Italy combines a physician-led ED model, regionally fragmented governance, and the absence of a national ANP regulatory framework. Although legislation recognizes “nurses with advanced competencies,” there is no uniform training standard or prescriptive authority, and implementation remains largely confined to pilot projects [153]. These systemic differences help explain variability in outcomes and external validity across the literature, and they underline the importance of adapting implementation strategies to local legal, organizational, and financial contexts.

A pragmatic route to standardization, despite this heterogeneity, would be a “core-plus-adaptation” model. The core specifies role profiles and competencies for ANPs— history and examination, clinical decision-making, protocol-based ordering and prescribing, imaging interpretation, and flow coordination—aligned with standardized graduate training and assessment. Building on this, modular, evidence-based protocols and order sets (e.g., nurse-initiated analgesia, antiemetics, or steroids; triage blood sampling; point-of-care algorithms) can be deployed with embedded safety checks and stop rules. Adaptation is explicit and bounded: derived modules must be tailored to the local legal scope of practice, capacity constraints (diagnostic access, workforce, financing), and ED contexts. Successful implementation of a “core-plus-adaptation” model would require tiered credentialing and governance aligned with education, supervised practice, and periodic re-credentialing. It would also depend on interprofessional investment, joint physician–nurse training, and engagement of ED leadership to build acceptance and role clarity.

This model may also counterbalance barriers identified in the included studies, which mirror those described in other settings [153, 154]. Common obstacles were the absence of standardized training programs, lack of shared protocols delineating roles and competencies, and gaps in professional policies and legal frameworks defining scope and accountability. Limited awareness and acceptance of the ANP role, together with uncertainty about responsibilities and expectations, further impede uptake. Conversely, strong interprofessional relationships, trust, and visible support from physicians and managers consistently facilitate implementation. Targeted educational initiatives, clear role definitions, and standardized guidelines—developed with input from professional bodies and policymakers—are also associated with smoother integration and more consistent outcomes [27, 155–159].

This review is not exempt from limitations. First, the exclusion of gray literature and the inclusion of only English, Italian, and German publications may have led to the omission of relevant data, although the search strategy identified a substantial and diverse body of evidence. Second, the included studies were heterogeneous in context, nurse profiles, and outcome metrics, and most were single-center observational designs, which may limit the generalizability of the findings and causal inference. Nevertheless, meaningful evidence can still be derived from observational and single-center studies in EDs, which often capture implementation dynamics, workflow integration, and patient-centered outcomes that controlled trials may not fully reflect. Future research should prioritize multicenter pragmatic trials, mixed-methods designs that integrate quantitative outcomes with qualitative insights on implementation, and meta-analyses pooling studies that use shared, protocol-anchored indicators. Comparative work across regulatory environments would also clarify how the scope of practice and training interact to shape effectiveness.

Conclusion

This review provides compelling evidence that ANP roles are ready for broader implementation in EDs, supported by a substantial body of research demonstrating safety, quality, and operational benefits. For clinicians, these finding highlight that well-trained ANPs can safely manage defined patient groups, improve flow, and enhance satisfaction without compromising outcomes. For health system governance and policymakers, the evidence supports integrating ANP roles into national ED workforce strategies as a cost-effective measure to alleviate overcrowding and optimize care delivery. To accelerate adoption, we recommend establishing national and regional frameworks defining core ANP competencies in EDs, aligning educational programs with these competencies, ensuring standardized preparation. We also propose implementation of pilot-to-scale pathways, incorporating context-specific adaptation where needed and exploring potential solutions for the above-mentioned barriers.

In an era of increasing ED demand and constrained resources, the question is no longer whether ANPs should play a central role in emergency care, but how quickly and effectively health systems can integrate and sustain these models.

Abbreviations

HCW

Healthcare worker

NCD

Non-communicable disease

HCF

Healthcare facility

ED

Emergency department

ENP

Emergency nurse practitioner

APN

Advanced practice nurse

ANP

Advanced nursing practice

TNO

Triage nurse ordering

RCT

Randomized clinical trial

LOS

Length of stay

FM

Flow manager

S&T

See and treat

EDAOLN

Emergency department ambulance off-load nurse

Author contributions

Initial concept and protocol for this scoping review were devised by Lamberti-Castronuovo A., Dal Molin A., and Franchini R. The comprehensive literature search, study selection, and data charting were conducted by Lamberti-Castronuovo A. and Franchini R. Data synthesis and drafting of the first manuscript version were performed by Malerba P. and Franchini R. All authors critically reviewed and revised the manuscript, approved the final version for publication, and agreed to be accountable for all aspects of the work.

Funding

Open access funding provided by Università degli Studi del Piemonte Orientale Amedeo Avogrado within the CRUI-CARE Agreement. No funding was received by any of the authors for this study.

Data availability

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of interest

The authors declare that they have no financial or non-financial interests that could be interpreted as potential conflicts of interest with respect to the research, authorship, or publication of this article.