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Reinforcing nursing roles through care journeys

Nurses play a critical role within healthcare systems as guardians of patient safety and patient-centered care. In this blog post we’ll be exploring why nurses are essential to redesign care delivery based on patient journeys and how their implementation reinforces the role of nursing in health institutions and patient-nurse relationships.

Matilde Ferreira

Matilde Ferreira

April 13, 2023 · 8 min read

An Elderly Man Talking to the Man in White Shirt while Holding Hands
Nurses play a critical role within healthcare systems as they are essential to delivering safe, high-quality, and patient-centered care. They are often on the front lines of patient care, providing compassionate and holistic care to individuals across the life cycle, from newborns to the elderly. On top of that, they have a distinctive position within the healthcare institutions - due to the wide scope of their work - combining both a comprehensive knowledge of patient flows between different settings and departments, and a stirring role when it comes to build multi-professional and multidisciplinary care plans. 
Nurses are the direct responsibles for deliver holistic patient care; they collaborate with other healthcare professionals to optimize patient outcomes, serving as advocates for patients, ensuring their physical, emotional, and psychosocial needs are met; and also play a pivotal role in health promotion, disease prevention, and patient education.  
All in all, their expertise makes them invaluable members of the healthcare team, contributing to the overall health and well-being of patients and their families. 

Taking advantage of the changing landscape of health care  

As the face of health care changes, so do the roles and opportunities for today’s nurses. The major ones include:  
  • Increased emphasis on technology
The use of technology in nursing has rapidly advanced over the last decade. This includes the adoption of electronic health records (EHRs), telehealth and telemedicine, remote patient monitoring, and other digital health solutions to improve patient care, streamline workflows, and enhance communication with patients, caregivers, and among healthcare team members.1-3
  • Expanded scope of practice
There has been a growing trend towards expanding the scope of practice for nurses in many countries, allowing them to take on more responsibilities and provide a wider range of services. This includes advanced practice roles such as nurse practitioners, nurse anesthetists, and clinical nurse specialists, who can manage patients' health conditions independently.4  
  • Increased emphasis on evidence-based practice
Evidence-based practice (EBP) has gained traction in nursing, with a growing emphasis on using the best available evidence, along with clinical expertise and patient values, to guide nursing care decisions.5 
  • Emphasis on interdisciplinary collaboration
Interdisciplinary collaboration and teamwork have become more prominent in nursing practice, with a growing recognition of the importance of collaboration among healthcare team members to provide safe, efficient, and patient-centered care. This includes improved communication and coordination among nurses, physicians, pharmacists, nutritionists, and other healthcare professionals.6-8 
Simultaneously, the challenges of current health systems are there for everyone to see: living longer is a reality, but living better is a challenge given the increased multimorbidity associated with ageing populations, younger generations are increasingly prioritizing health and well-being, and there is also a growing expectation for convenience and accessibility (including for innovative therapeutics and technological solutions), increasing pressure on global systems.
On the other side, there is an unprecedented critical workforce shortage that has been exacerbated by the COVID-19 pandemic. According to the World Health Organization, by 2030 there will be a shortage of more than 10 million professionals worldwide,9about half of whom will be nurses.10 
As such, health systems need to adapt to meet the continuously increasing demand, and from a nursing perspective there are, in current practice, several opportunities for process improvement empowering nurses with greater autonomy, efficiency and efficacy, by redesigning care with digital care journeys, with a focus on patient safety and patient education and self-care.
Why and how? That’s exactly what we’ve explored in our last webinar

Care journeys design and implementation: nurses' roles in every step of the way  

The role of nurses involves coordinating and managing the care of patients throughout their journey, from admission to discharge, long lasting follow-up, and for every transition to another care setting. 
At UpHill, we define the process of care journeys design, adjustment, implementation and evaluation in 4 stages and, as described below, nurses play a critical role in all of them: 

1. Care journey mapping and design | Nurses playing as gatekeepers of patients’ flow  

Given the deep knowledge hold about the patient's journey through several settings - from inpatient, emergency room, operating room, day hospital, home hospitalization, etc. - and their detailed understanding about the institution structure, nursing teams have a pivotal role in supporting the construction of the care journeys, developing holistic care plans based on evidence-based practice and patient values and expectations, the decisions to be made and by whom, collaborating with other teams to set appropriate goals and interventions for each stage of the care journey.  

2. Care journey implementation | Nurses leading change management in healthcare institutions 

This step is crucial to fit best practices to the institution's unique context. Nurses play a key role in communicating with other healthcare professionals, hospital managers, IT managers and other staff, and anticipating patients’ needs and values in the wider socio-economic context in which the institution is placed. They ensure that all members of the healthcare team are working together seamlessly, facilitating effective communication, and coordinating services, and resources, as needed. Once again, nurses' knowledge of the institution's functioning is relevant to ensure that it is out of line with reality and to bring all the people (including patients, families, and caregivers) into the project. 

3. Care provision | Nurses arising as case managers 

Nurses provide direct patient care, implementing the care plan, administering medications, monitoring patients' condition, participating in referrals, and evaluating the effectiveness of interventions. They also educate patients and families about the care journey, including self-care interventions, managing symptoms, and understanding the goals of care. With a digital care journey, nursing teams have visibility on the patient's progress, accurately identifying the moments when decisions need to be anticipated, therapeutics need to be adjusted, or the patient need to be redirected to another level of care, getting greater autonomy in care provision. Interprofessional collaboration is strengthened by the fact that all have access to the same information, and communication with the patient is also reinforced by the mechanisms of asynchronous communication and regular follow-up.  
Finally, such tools enable nurses to improve patient prioritization, based on clinical criteria - instead of first-in first-out (FIFO) approach - thus driving healthcare institutions to improve allocative efficiency, by deciding which patients should be seen, and whom should be seen first, when demand is great, and resources are limited. 

4. Monitoring & evaluation | Nurses as promoters of quality improvement 

Nurses are responsible for accurate and timely documentation of patient care, including assessments, interventions, and outcomes. They participate in quality improvement initiatives to continuously evaluate and improve the care journey for patients. Empowered by care journeys, nursing teams access analytical data that allows them to assess compliance with best practices, identifying the most critical points of the journey and areas for improvement, with a special focus on patient safety data. Lastly, such data can be used for research purposes and to inform better health policies to improve patient and health outcomes. 
If interested in going deeper on this subject download our ebook about concepts, methods, and challenges surrounding care journeys implementation and watch the webinar in which there were shared personal experiences about implemented projects. 


  1. Bailey , S. (2023, March 22). How technology has changed the role of Nursing. Nurse Journal. Retrieved April 13, 2023, from
  2. Whende, M. C. (2021, April 29). 2020: Emerging Technology in global nursing care. HIMSS. Retrieved April 13, 2023, from 
  3. BMJ 2021;373:n1190
  4. Judith A. Oulton, Patricia Caldwell, in International Encyclopedia of Public Health (Second Edition), 2017
  5.  Stevens, K., (May 31, 2013) "The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas" OJIN: The Online Journal of Issues in Nursing Vol. 18, No. 2, Manuscript 4.
  6. Evert Schot, Lars Tummers & Mirko Noordegraaf (2020) Working on working together. A systematic review on how healthcare professionals contribute to interprofessional collaboration, Journal of Interprofessional Care, 34:3, 332-342, DOI: 10.1080/13561820.2019.1636007
  7. Dahlke, S., Hunter, K. F., Reshef Kalogirou, M., Negrin, K., Fox, M., & Wagg, A. (2020). Perspectives about Interprofessional Collaboration and Patient-Centred Care. Canadian journal on aging = La revue canadienne du vieillissement39(3), 443–455.
  8. Fox, A., & Reeves, S. (2015). Interprofessional collaborative patient-centred care: a critical exploration of two related discourses. Journal of interprofessional care29(2), 113–118.
  9. World Health Organization. (n.d.). Health workforce. World Health Organization. Retrieved April 13, 2023, from 
  10. World Health Organization. (n.d.). Nursing and midwifery. World Health Organization. Retrieved April 13, 2023, from 
Matilde Ferreira

Matilde Ferreira

Content Strategy & Communication Manager

Graduated in Communication Sciences, early on fell in love with storytelling. Started off as a journalist and then pivoted to the public relations world, she was always driven to craft relevant stories and bring them to the stage.

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