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Evolution of advanced practice nursing in acute care in Germany: A cross-sectional study of nurses’ scope of practice
International Nursing Review
Abstract
Aim
To describe activities and professional characteristics of nurses in expanded roles in acute care in Germany and achieve a greater understanding of the current situation of advanced practice nursing.
Background
Advanced practice nursing plays an important role in meeting increased demands in healthcare and promoting high-quality care.
Introduction
In Germany, advanced practice nursing is still at an early stage with a lack of studies describing the scope of practice of nurses in expanded roles.
Methods
We conducted a cross-sectional-study using a paper-and-pencil questionnaire. In a nationwide convenience sample, we surveyed nurses with an academic degree, who work in an acute care hospital and take over expanded roles in direct patient care. Reporting followed the STROBE checklist.
Results
Of 108 eligible nurses, 84 (77%) completed the survey. The majority had a Master's degree (63.1%) and the average work experience was 18.2 years. Participants carried out activities in all the domains that were queried (direct clinical practice, guidance and coaching, consultation, leadership and research) with differences within and between domains. Foci were on direct clinical practice and coaching and guidance.
Discussion
In Germany, qualifications are nearing the international standard of advanced practice nursing. Results suggest that participants partly undertake activities within the scope of registered nurses' practice that do not correspond fully to their formal qualifications.
Conclusion and implications for nursing and/or health policy
In order to foster the role development of expanded practice nurses in Germany, political efforts are needed in terms of training (e.g. specific Master's programmes), funding of corresponding positions in practice and control mechanisms (e.g. professional registration).
... In the first phase of the ENROLE-acute project, we comprehensively developed the complex intervention based on two systematic reviews, two surveys [31], one qualitative interview study, and two workshops with relevant stakeholders from clinical practice, research, and representative organisations of people with cognitive impairment. We will publish details of intervention development elsewhere. ...
Background
For people with cognitive impairment, hospitalisation is challenging and associated with adverse events as well as negative outcomes resulting in a prolonged hospital stay. Person-centred care can improve the quality of care and the experience of people with cognitive impairment during hospitalisation. However, current care processes in German hospitals are rarely person-centred. To enable successful implementation of person-centred care on hospital wards, change agents within the interprofessional team are key. The aim of this study is to test the feasibility and initial effects of a newly developed complex person-centred care intervention for people with cognitive impairment provided by expanded practice nurses in acute care.
Methods
We will conduct an exploratory non-randomised controlled clinical trial with accompanying process and cost evaluation with three intervention and three control wards at one university hospital. The person-centred care intervention consists of 14 components reflecting the activities of expanded practice nurses within the interprofessional team on the intervention wards. The intervention will be implemented over a six-month period and compared with optimised care on the control wards. We will include people aged 65 years and older with existing cognitive impairment and/or at risk of delirium. The estimated sample size is 720 participants. The primary outcome is length of hospital stay. Secondary outcomes include prevalence of delirium, prevalence of agitation, sleep quality, and person-centred care. We will collect patient level data at six time points (t1 admission, t2 day 3, t3 day 7, t4 day 14, t5 discharge, t6 30 days after discharge). For secondary outcomes at staff level, we will collect data before and after the intervention period. The process evaluation will examine degree and quality of implementation, mechanisms of change, and the context of the complex intervention. The economic evaluation will focus on costs from the hospital’s perspective.
Discussion
The ENROLE-acute study will provide insights into the effectiveness and underlying processes of a person-centred care intervention for people with cognitive impairment provided by expanded practice nurses on acute hospitals wards. Results may contribute to intervention refinement and evidence-based decision making.
Trial registration
Current controlled trials: ISRCTN81391868. Date of registration: 12/06/2023. URL: https://doi.org/10.1186/ISRCTN81391868
Aim
To explore the roles and training of advanced practice nurses specialised in acute pain management, as reported in the current literature.
Design
Scoping review.
Data Sources
We searched PubMed, Scopus and CINAHL in December 2023 to identify relevant studies published from 1996.
Methods
Relevant literature was identified, screened, and analysed using a structured scoping review process. Two reviewers independently selected and extracted data from eligible studies, with a third reviewer resolving any disagreements.
Results
A total of 1682 records were screened, and 36 studies met the inclusion criteria. Four main themes emerged: job titles, roles, training, and barriers. The review revealed substantial variation in job titles and role descriptions across clinical settings and geographic regions, with more comprehensive role definitions found in countries like the United States and the United Kingdom. Training pathways, including postgraduate qualifications and certification, varied significantly and many low‐ and middle‐income countries lacked structured training frameworks. Barriers identified included regulatory limitations, insufficient educational infrastructure and lack of legal authority to practice.
Conclusion
This review highlights significant international variation in the definition, training and regulation of advanced practice nurses in acute pain management. There is an urgent need to develop global standards, including unified competencies and certification pathways, to ensure consistent and effective care.
Implications for the Profession
Standardising competencies and training will support role recognition, improve consistency in clinical practice and promote high‐quality care for individuals experiencing acute pain.
Impact
This review addresses the global inconsistency in role definition and training of advanced practice nurses in acute pain management. Findings may inform educators, health professionals, policymakers and regulators, particularly in resource‐limited settings.
Reporting Method
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses extension for Scoping Reviews (PRISMA‐ScR).
Patient or Public Contribution
No patient or public contribution.
Emergency Nurse Practitioners (ENPs) are reshaping emergency care globally. This chapter charts their journey from inception to current practice across various countries. It describes how ENPs' roles have expanded beyond patient care to encompass leadership, education, and research. The impact is significant: ENPs improve care access, reduce wait times, and enhance patient satisfaction. Yet, challenges remain, including unclear role boundaries and regulatory hurdles. The chapter explores future possibilities for ENPs in areas like crisis management and healthcare technology. To fully leverage ENPs' potential, ongoing efforts are needed in standardizing education, clarifying regulations, and fostering professional acceptance. As healthcare demands evolve, ENPs are set to play an increasingly crucial role in delivering efficient, high-quality emergency care.
Aim
To describe psychometric validation of the newly developed Advanced Practice Nurse Task Questionnaire.
Design
Cross‐sectional quantitative study.
Methods
The development of the questionnaire followed an adapted version of the seven steps described in the guide by the Association for Medical Education in Europe. A nationwide online survey tested the construct and structural validity and internal consistency using an exploratory factor analysis, Cronbach's alpha coefficient and a Kruskal–Wallis test to compare the hypotheses.
Results
We received 222 questionnaires between January and September 2020. The factor analysis produced a seven‐factor solution as suggested in Hamric's model. However, not all item loadings aligned with the framework's competencies. Cronbach's alpha of factors ranged between .795 and .879. The analysis confirmed the construct validity of the Advanced Practice Nurse Task Questionnaire. The tool was able to discriminate the competencies of guidance and coaching, direct clinical practice and leadership across the three advanced practice nurse roles clinical nurse specialist, nurse practitioner or blended role.
Conclusion
A precise assessment of advanced practice nurse tasks is crucial in clinical practice and in research as it may be a basis for further refinement, implementation and evaluation of roles.
Impact
The Advanced Practice Nurse Task Questionnaire is the first valid tool to assess tasks according to Hamric's model of competencies independently of the role or the setting. Additionally, it distinguishes the most common advanced practice nurse roles according to the degree of tasks in direct clinical practice and leadership. The tool may be applied in various countries, independent of the degree of implementation and understanding of advanced nursing practice.
Reporting Method
The STARD 2015 guideline was used to report the study.
Patient or Public Contribution
No patient or public contribution.
A career ladder for nurses, including several levels of nursing practice and specific roles for advanced practice nurses, was introduced in Hong Kong around the turn of the century. To date no studies have distinguished the practices of advanced practice nurses in Hong Kong. This cross‐sectional study, conducted between November 2020 and March 2021, aims to identify and differentiate the practice patterns of advanced practice nurses by utilizing the Advanced Practice Role Delineation tool. A total of 191 responses was obtained. Three roles were identified: nurse consultant, advanced practice nurse, and advanced practice nurse in management. From the advanced practice nursing domains, the nurses were most frequently involved in Education and Direct Comprehensive Care activities, while Research and Publication and Professional Leadership activities were the least utilized. Identifying activities in various nursing roles helps to differentiate their responsibilities and provides new insights for role utilization and support. Although the role characteristics are shaped by country contexts, research evidence on practice patterns may be used to support international discussion and efforts to promote role clarity and effective role introduction and optimization.
Background
To improve health care in rural areas, especially for increasing numbers of people with chronic diseases, academically qualified nurses could take over expanded roles to meet the challenges of an ageing society and a decreasing number of General Practitioners (GPs). In the project “HandinHand” (HiH), qualified nurses (Expert nurses, ENs) will carry out home visits to older people with chronic diseases over a period of six months. ENs will prepare a care plan in cooperation with GPs to stabilise the care situation and avoid unplanned hospital admissions and GP visits. The process evaluation aims to provide an in-depth analysis of the implementation process and gather important information on barriers and facilitators to the implementation of ENs as a complementary health care structure in primary care, taking into account several context factors.
Methods
Based on the Medical Research Council (MRC) Framework for complex interventions, a logic model was developed and applied as the basis for data collection. Qualitative and quantitative data will be collected during the study. A mixed methods approach should allow to gain important insights from participants (e.g. ENs, GPs, patients) involved in the study as well as relevant stakeholders. Semi-structured interviews and surveys will be conducted. Data analysis will be based on the logical model, combining qualitative and quantitative data. Qualitative data will be analysed inductively-deductively using qualitative thematic framework analysis.
Discussion
The process evaluation will provide guidance and conclusions on further development and transferability. Of particular interest is the expanded role of ENs in primary care, which has barely been implemented in Germany and can be seen as a precursor to the development of an Advanced Practice Nursing (APN) role in primary care.
Background
Stronger healthcare models are increasingly sought to address new population needs, health workforce inefficiencies and nursing shortages. One strategy is to focus on employees’ strengths to capitalize on their competencies and maximize their scope of practice.
Introduction
Globally, there is an exponential demand for advanced practice nursing services. This study aimed to identify the roles and positions of nurses who align with APN defining criteria at all levels of care in Catalonia, Spain.
Methods
The first step of the study included the translation and validation to Catalan of the Advanced Practice Nurse Role Delineation Tool (IDREPA) and step 2 comprised a multicentre cross-sectional study, in which 126 healthcare centres participated: 1209 nurses were included in the study. The STROBE checklist was used to report this study.
Results
Transcultural equivalence and validation of the instrument showed a content validity index of 0.958 and the reliability of the questionnaire. The instrument identified 269 nurses who align with international APN defined criteria. They worked in specialized care, mental healthcare and primary and community care, especially in chronic conditions, ageing and end-of-life care.
Discussion
Most areas of Catalonia have access to nurses practicing at APN defining criteria. These nurses were developed as an optimal resource to respond to patient needs in the context of study. Both recognition and strategic implementation are necessary to apply their full competencies to solve healthcare problems.
Conclusion
Understanding the supply of services delivered by nurses practicing at an advanced level and their scope of practice may lay the foundations for effective workforce planning in a dynamic context. Nurses who align with APN defining criteria are working mainly in large acute services without regulation and recognition.
Implications for nursing
Advanced practice nurses show the value of their role and activities in healthcare services.
Implications for health policy
Promoting the establishment of APN defining criteria that includes credentialing and a regulatory framework within international guidelines should be a priority to make an impact on healthcare policy.
This analysis of the German health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Germany's health care system is often regarded as one of the best health care systems in the world, offering its population universal health insurance coverage and a comprehensive benefits basket with comparably low cost-sharing requirements. It provides good access to care with free choice of provider and short waiting times, which is partly due to good infrastructure with a dense network of ambulatory care physicians and hospitals, and a quantitatively high level of service provision. With the largest economy in the EU it is not surprising that Germany spends more than other countries on health, with most financing coming from public funds. The country had the highest per capita spending in the EU in 2018. In relation to overall health expenditure and available resources, a very high number of services is provided across sectors, particularly in hospital and ambulatory care. This can be seen as achieving a considerable level of technical efficiency. Given the high volumes, however, there are questions about the oversupply of services, as well as some comparatively moderate health and quality outcomes; from this perspective, there are signs that there is room for improvement in how the system allocates resources. Additional challenges in the German health system may be identified in: (1) the strong separation of ambulatory and inpatient care in terms of organization and payment, which can hinder the coordination and continuity of patient treatment; (2) the coexistence of statutory health insurance (SHI) and substitutive private health insurance (PHI), which weakens the principle of solidarity; and (3) a complex stewardship framework which promotes incrementalism and makes it more difficult to implement reforms.
Zusammenfassung
Einleitung
Eine sinnvolle Einbindung von Pflegefachpersonen mit Hochschulabschluss in die Versorgungsabläufe wird international häufig mit besseren Behandlungsergebnissen bei den Patient*innen assoziiert. In Deutschland fehlt es derzeit noch an verlässlichen Zahlen über Absolvent*innen und deren Aufgabenfeldern. Ziel dieser Erhebung war daher, durch Wiederholung einer früheren Erhebung erneut den Anteil von Pflegefachpersonen mit Bachelor- oder Masterabschlüssen in der direkten Patient*innenversorgung zu ermitteln.
Methode
In einer Querschnittserhebung wurden die Pflegedirektor*innen der Universitätskliniken und Medizinischen Hochschulen (UK) Deutschlands mittels einer standardisierten Befragung nach der Anzahl der Pflegefachpersonen mit Hochschulabschlüssen (Bachelor, Master und Doktor) gefragt. Weitere Fragen betrafen deren Aufgabengebiete und Integrationsmaßnahmen. Die Daten wurden mittels deskriptiver Statistik ausgewertet.
Ergebnisse
Insgesamt konnten n = 29 gültige Fragebögen aus 35 UK in die Analyse eingeschlossen werden, daraus ergibt sich eine Rücklaufquote von 82,85%. Für insgesamt 18 UK konnte eine Steigerung der hochschulisch qualifizierten Pflegefachpersonen um n = 786, von 2015 (n = 593) auf 2018 (n = 1379) erreicht werden. Der Anteil an Pflegefachpersonen mit Hochschulabschluss in den teilnehmenden UK liegt bei 3,16% (SD = 1,66; Min - Max = 1,09 - 6,69; Q1 - Q3 = 1,49 - 4,04; 95% KI = 2,30 – 3,95). In der direkten Versorgung beträgt der Anteil 2,11% (SD = 1,40; Min – Max = 0,47 - 5,42; Q1 – Q3 = 0,87 – 3,16; 95% KI 1,36 - 2,76). Die Aufgabenschwerpunkte liegen im Bereich der Regelversorgung und Patient*innenedukation (Bachelorabsolvent*innen), der evidenzbasierten Pflegepraxisentwicklung (Masterabsolvent*innen) und Forschung (promovierte Absolvent*innen).
Diskussion
Im Vergleich zu 2015 ist der Anteil hochschulisch qualifizierter Pflegefachpersonen zwar angestiegen, doch er liegt immer noch auf einem sehr niedrigen Niveau. Die Hochschulabsolvent*innen nehmen versorgungs- und entwicklungsrelevante Aufgaben wahr, doch besteht hinsichtlich ihrer Aufgabengebiete Bedarf an kompetenzorientierter Differenzierung.
ABSTRACT
Background
Workload and workforce issues in primary care are key drivers for the growing international trend to expand nursing roles. Advanced nurse practitioners are increasingly being appointed to take on activities and roles traditionally carried out by doctors. Successful implementation of any new role within multidisciplinary teams is complex and time-consuming, therefore it is important to understand the factors that may hinder or support implementation of the advanced nurse practitioner role in primary care settings.
Objectives
To identify, appraise and synthesise the barriers and facilitators that impact implementation of advanced practitioner roles in primary care settings.
Methods
A scoping review conducted using the Arksey and O'Malley (2005) framework and reported in accordance with PRISMA-ScR. Eight databases (Cochrane Library, Health Business Elite, Kings Fund Library, HMIC, Medline, CINAHL, SCOPUS and Web of Science) were searched to identify studies published in English between 2002 and 2017. Study selection and methodological assessment were conducted by two independent reviewers. A pre-piloted extraction form was used to extract the following data: study characteristics, context, participants and information describing the advanced nurse practitioner role. Deductive coding for barriers and facilitators was undertaken using a modified Yorkshire Contributory Framework. We used inductive coding for barriers or facilitators that could not be classified using pre-defined codes. Disagreements were addressed through discussion. Descriptive data was tabulated within evidence tables, and key findings for barriers and facilitators were brought together within a narrative synthesis based on the volume of evidence.
Findings
Systematic searching identified 5976 potential records, 2852 abstracts were screened, and 122 full texts were retrieved. Fifty-four studies (reported across 76 publications) met the selection criteria. Half of the studies (n=27) were conducted in North America (n=27), and 25/54 employed a qualitative design. The advanced nurse practitioner role was diverse, working across the lifespan and with different patient groups. However, there was little agreement about the level of autonomy, or what constituted everyday activities. Team factors were the most frequently reported barrier and facilitator. Individual factors, lines of responsibility and ‘other’ factors (i.e. funding), were also frequently reported barriers. Facilitators included individual factors, supervision and leadership and ‘other’ factors (i.e. funding, planning for role integration).
Conclusion
Building collaborative relationships with other healthcare professionals and negotiating the role are critical to the success of the implementation of the advanced nurse practitioner role. Team consensus about the role and how it integrates into the wider team is also essential.
Keywords
Advanced Practice Nursing
Barriers
Facilitators
Implementation
Primary Care
Background:
Current and expected problems such as ageing, increased prevalence of chronic conditions and multi-morbidity, increased emphasis on healthy lifestyle and prevention, and substitution for care from hospitals by care provided in the community encourage countries worldwide to develop new models of primary care delivery. Owing to the fact that many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency, and quality of care. This is the first update of the Cochrane review published in 2005.
Objectives:
Our aim was to investigate the impact of nurses working as substitutes for primary care doctors on:• patient outcomes;• processes of care; and• utilisation, including volume and cost.
Search methods:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (www.cochranelibrary.com), as well as MEDLINE, Ovid, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and EbscoHost (searched 20.01.2015). We searched for grey literature in the Grey Literature Report and OpenGrey (21.02.2017), and we searched the International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov trial registries (21.02.2017). We did a cited reference search for relevant studies (searched 27.01 2015) and checked reference lists of all included studies. We reran slightly revised strategies, limited to publication years between 2015 and 2017, for CENTRAL, MEDLINE, and CINAHL, in March 2017, and we have added one trial to 'Studies awaiting classification'.
Selection criteria:
Randomised trials evaluating the outcomes of nurses working as substitutes for doctors. The review is limited to primary healthcare services that provide first contact and ongoing care for patients with all types of health problems, excluding mental health problems. Studies which evaluated nurses supplementing the work of primary care doctors were excluded.
Data collection and analysis:
Two review authors independently carried out data extraction and assessment of risk of bias of included studies. When feasible, we combined study results and determined an overall estimate of the effect. We evaluated other outcomes by completing a structured synthesis.
Main results:
For this review, we identified 18 randomised trials evaluating the impact of nurses working as substitutes for doctors. One study was conducted in a middle-income country, and all other studies in high-income countries. The nursing level was often unclear or varied between and even within studies. The studies looked at nurses involved in first contact care (including urgent care), ongoing care for physical complaints, and follow-up of patients with a particular chronic conditions such as diabetes. In many of the studies, nurses could get additional support or advice from a doctor. Nurse-doctor substitution for preventive services and health education in primary care has been less well studied.Study findings suggest that care delivered by nurses, compared to care delivered by doctors, probably generates similar or better health outcomes for a broad range of patient conditions (low- or moderate-certainty evidence):• Nurse-led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary care makes little or no difference to the number of deaths (low-certainty evidence).• Blood pressure outcomes are probably slightly improved in nurse-led primary care. Other clinical or health status outcomes are probably similar (moderate-certainty evidence).• Patient satisfaction is probably slightly higher in nurse-led primary care (moderate-certainty evidence). Quality of life may be slightly higher (low-certainty evidence).We are uncertain of the effects of nurse-led care on process of care because the certainty of this evidence was assessed as very low.The effect of nurse-led care on utilisation of care is mixed and depends on the type of outcome. Consultations are probably longer in nurse-led primary care (moderate-certainty evidence), and numbers of attended return visits are slightly higher for nurses than for doctors (high-certainty evidence). We found little or no difference between nurses and doctors in the number of prescriptions and attendance at accident and emergency units (high-certainty evidence). There may be little or no difference in the number of tests and investigations, hospital referrals and hospital admissions between nurses and doctors (low-certainty evidence).We are uncertain of the effects of nurse-led care on the costs of care because the certainty of this evidence was assessed as very low.
Authors' conclusions:
This review shows that for some ongoing and urgent physical complaints and for chronic conditions, trained nurses, such as nurse practitioners, practice nurses, and registered nurses, probably provide equal or possibly even better quality of care compared to primary care doctors, and probably achieve equal or better health outcomes for patients. Nurses probably achieve higher levels of patient satisfaction, compared to primary care doctors. Furthermore, consultation length is probably longer when nurses deliver care and the frequency of attended return visits is probably slightly higher for nurses, compared to doctors. Other utilisation outcomes are probably the same. The effects of nurse-led care on process of care and the costs of care are uncertain, and we also cannot ascertain what level of nursing education leads to the best outcomes when nurses are substituted for doctors.
Objectives:
To identify and summarize the common clinical settings, interventions, and outcomes of nurse practitioner care specific to older people.
Design:
Scoping review of the international published and grey literature.
Data sources:
A structured literature search was conducted of CINAHL, EMBASE, MEDLINE, Google Scholar, and Cochrane Collaboration and Joanna Briggs Institute databases.
Review methods:
Following the Arksey and O'Malley framework, randomized controlled and quasi-experimental studies of Masters-prepared nurse practitioners providing care for patients over 65 years were included. Studies were reviewed independently by two investigators. Data were extracted, collated by setting, summarized in tables and synthesized for analysis.
Results:
In total, 56 primary research studies from four countries and 23 systematic reviews were identified. Primary studies were conducted in primary care (n=13), home care (n=14), long-term care (n=10), acute/hospital care (n=9), and transitional care (n=10). Nurse practitioner interventions included substitutive as well as a supplementation NP role elements to meet specific unmet patient care needs. Studies examined six main outcome measures: service utilization (n=41), cost (n=24), length of stay (n=14), health indices (n=44), satisfaction (n=14) and quality of life (n=7). Cumulatively, nurse practitioners demonstrated enhanced results in 83/144 (58%) of outcomes compared to physician-only or usual care. The most commonly measured financial-related outcome was service utilization (n=41) and benefits were frequently reported in home care (8/9, 89%) and long-term care (7/10, 70%) settings. Among patient and care-related outcomes health indices were most frequently measured (n=44). Primary care most frequently reported improved health indices (11/13, 85%). Transitional care reported improved outcomes across all measures, except for service utilization.
Conclusions:
This review demonstrates improved or non-inferiority results of nurse practitioner care in older people across settings. More well-designed, rigorous studies are needed particularly in relation to costs. The results of this review could be used for future systemic review of effectiveness of NP care specific to older people. Despite the demonstrated NP role value, barriers to implementing the nurse practitioner role persist internationally and more work is needed to develop and promote these roles.
This review of nurse education and regulation in selected OECD countries forms part of ongoing work on contemporary nursing careers and working lives, based at the National Nursing Research Unit, King’s College London. The review was commissioned by the Department of Health to inform their work in considering the UK’s position in relation to the Bologna declaration and changes that may emanate from the implementation of Modernising Nursing Careers (DH 2006). While much of the information in the review was obtained from publications and websites, we also contacted key personnel in most of the countries included for an up-to-date review of developments in their country and would like to thank them all for providing this information.
To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings.
Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.
Quantitative systematic review.
Twelve electronic databases were searched (1966–2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.
Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.
Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.
Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case–control and cross-sectional studies. We convened a 2-day workshop in September 2004, with methodologists, researchers, and journal editors to draft a checklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE Statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case–control, or cross-sectional studies. A detailed Explanation and Elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine and Epidemiology. We hope that the STROBE Statement will contribute to improving the quality of reporting of observational studies.
This article compares the professionalization and educational standards of Advanced Practice Nursing in the United States, Canada, Germany, Austria, and Switzerland with specific attention to geographical, political, and professional factors – both current and historical – influencing the evolution of these nurse leaders. A review of the literature, scientific articles, governmental regulatory texts, and legislative codes from each country, was performed. Patterns related to the geographical, political and professional context of nursing in each country were identified with comparative insights on the evolution of the discipline. Advancement of the nursing discipline is apparent in each country over the last century, although at differing rates. The disparity in development and level of autonomous practice for Advanced Practice Nurses in each country can be better understood in the context of historical, geographical, political and professional development. This review of the literature was combined with a comparative analysis and offers insights to inform nurses in education, leadership, practice, and advocacy interested in advancing the professionalization of advanced practice nursing internationally.
Zusammenfassung. Hintergrund: Die Entwicklung von Advanced Practice Nurses (APN-Rollen) im akutstationären Setting in Deutschland ist stark von Kontextfaktoren abhängig. Diese Etablierung von APN-Rollen in der direkten Patientenversorgung stellt einen tiefgreifenden Organisationsentwicklungsprozess dar. Im Jahr 2010 begann im Florence-Nightingale-Krankenhaus in Düsseldorf die Implementierung von APN-Rollen. Ziel: Unsere Erfahrung in der Entwicklung von APN-Rollen und darüber hinaus die Identifikation von beeinflussenden Faktoren zu reflektieren. Die Erhebung fördernder und hemmender Faktoren soll zukünftige APN-Rollenentwicklungen und Interventionen unterstützen. Methoden: Mithilfe des Consolidated Framework for Implementation Research (CFIR) haben vier Pflegeexpertinnen APN einen teilstrukturierten Rückblick vorgenommen. Hierzu wurde der zyklische Prozess der kritischen Selbstreflexion nach Titchen (2009) verwendet. Ergebnisse: Die Einflussfaktoren wurden in Kategorien zusammengefasst. Differenziert dargestellt werden die Kategorien: Unterstützung durch die Managementebene, Erkennen von Veränderungsbedarf, Fachliche Expertise, Präsenz vor Ort, Selbstwirksamkeit und persönliche Eigenschaften sowie Rollenklarheit. Diskussion: Die Implementierung von APN-Rollen braucht Zeit und Ausdauer, sowohl von der Organisation als auch von den jeweiligen Pflegeexpert_innen APN. Die Erlangung von Rollenklarheit ist in diesem Prozess substanziell. Grenzen und Transfer: Dieser Reflexionsbericht stellt kontextbezogene Ergebnisse dar. Die identifizierten Einflussfaktoren können jedoch eine Hilfestellung für zukünftige Implementierungsprozesse und Entwicklungen von APN-Rollen darstellen.
This chapter presents an overview about advanced nursing practice in Germany, which is an emerging concept in the healthcare service. Currently the spheres of work of the majority of advanced practice nurses are comparable to clinical nurse specialists. They provide direct clinical care to patients, support and empower nurses and/or other healthcare staff as well as strive towards changes within the organisation. Widely used are Hamric’s Integrative Model of Advanced Practice Nursing and the PEPPA framework to provide guidance regarding the competencies and implementation of ANP. Missing regulation within nursing poses a big hinderance in this process. As an example of ANP practice in Germany serves the implementation of delirium management. Also described are education and professional developments with regard to ANP. An outlook finishes this chapter.
Aim
To explore the practice profile and competencies of advanced practice nurses (APN) and midwives (AMPs), and factors associated with task non‐execution.
Background
Advanced practitioner roles are increasingly implemented internationally. Unofficial role introduction led to confusion regarding task performance. Studies examining associations between APNs’/AMPs’ task performance and competency levels, and factors associated with task non‐execution are lacking.
Method
A cross‐sectional study among APNs/AMPs in Flanders (Belgium) explored tasks and competencies in seven domains: clinical/professional leadership, change management/innovation, research, clinical expertise/guidance/coaching, consultation/consultancy, multidisciplinary cooperation/care coordination, and ethical decision‐making. Task performance and competency level frequencies were calculated. Regression analysis identified factors associated with task non‐execution on domain/item level.
Results
Participants (n=63) executed tasks in all domains. Task non‐execution related to research and clinical expertise was associated with work setting; task non‐execution regarding care coordination and ethical decision‐making was associated with competency perception. Several tasks were performed by few APNs/AMPs despite many feeling competent. Five of ten tasks performed by fewest participants belonged to the leadership domain.
Conclusion and implications for nursing and midwifery management
Supervisors could play an important part in APNs’/AMPs’ role development, especially regarding leadership and tasks executed by few participants. Future studies should provide in‐depth knowledge on task non‐execution.
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Background:
A variety of advanced practice nursing roles and titles have proliferated in response to the changing demands of a population characterized by increasing age and chronic illness. Whilst similarly identified as advanced practice roles, they do not share a common practice profile, educational requirements or legislative direction. The lack of clarity limits comparative research that can inform policy and health service planning.
Aims:
To identify advanced practice roles within nursing titles employed in New Zealand and practice differences between advanced practice and other roles.
Method:
Replicating recent Australian research, 3255 registered nurses/nurse practitioners in New Zealand completed the amended Advanced Practice Delineation survey tool. The mean domain scores of the predominant advanced practice position were compared with those of other positions. Differences between groups were explored using one-way ANOVA and post hoc between group comparisons.
Results:
Four nursing position bands were identified: nurse practitioner, clinical nurse specialist, domain-specific and registered nurse. Significant differences between the bands were found on many domain scores. The nurse practitioner and clinical nurse specialist bands had the most similar practice profiles, nurse practitioners being more involved in direct care and professional leadership.
Conclusions:
Similar to the position of clinical nurse consultant in Australia, those practicing as clinical nurse specialists were deemed to reflect the threshold for advanced practice nursing. The results identified different practice patterns for the identified bands and distinguish the advanced practice nursing roles.
Implications for nursing policy:
By replicating the Australian study of Gardener et al. (2016), this NZ paper extends the international data available to support more evidence-based nursing workforce planning and policy development.
Aims
To provide the best available evidence to determine the impact of nurse practitioner services on cost, quality of care, satisfaction and waiting times in the emergency department for adult patients.
Background
The delivery of quality care in the emergency department is emerging as one of the most important service indicators in health delivery. Increasing service pressures in the emergency department have resulted in the adoption of service innovation models: the most common and rapidly expanding of these is emergency nurse practitioner services. The rapid uptake of emergency nurse practitioner service in Australia has outpaced the capacity to evaluate this service model in terms of outcomes related to safety and quality of patient care. Previous research is now outdated and not commensurate with the changing domain of delivering emergency care with nurse practitioner services.
Data sources: A comprehensive search of four electronic databases from 2006-2013 was conducted to identify research evaluating nurse practitioner service impact in the emergency department. English language articles were sought using MEDLINE, CINAHL, Embase and Cochrane and included two previous systematic reviews completed five and seven years ago.
Review methods: A three step approach was used. Following a comprehensive search, two reviewers assessed all identified studies against the inclusion criteria. From the original 1013 studies, 14 papers were retained for critical appraisal on methodological quality by two independent reviewers and data were extracted using standardised tools.
Results
Narrative synthesis was conducted to summarise and report the findings as insufficient data was available for meta-analysis of results. This systematic review has shown that emergency nurse practitioner service has a positive impact on quality of care, patient satisfaction and waiting times. There was insufficient evidence to draw conclusions regarding outcomes of a cost benefit analysis.
Conclusion
Synthesis of the available research attempts to provide an evidence base for emergency nurse practitioner service to guide healthcare leaders, policy makers and clinicians in reform of emergency service provision. The findings suggest that further high quality research is required for comparative measures of clinical and service effectiveness of emergency nurse practitioner service. In the context of increased health service demand and the need to provide timely and effective care to patients, such measures will assist in evidence based health service planning.
In this systematic literature review, we analyzed and synthesized the literature on one specialized advance practice nursing role in three countries for the purpose of describing and comparing these roles, as well as discussing whether an international consensus of the advance practice nursing definition is possible. A systematic search on CINAHL and PubMed Medline was conducted in 2011 to search the literature on the nurse consultant in the UK, the clinical nurse specialist in the USA, and the clinical nurse consultant in Australia. The studies (n = 42) were analyzed and combined using qualitative content analysis method. The roles of the nurse consultant, clinical nurse specialist, and clinical nurse consultant were similar. The variation in the roles appears to derive from organizational or individual choices, not the country in question. The study process comprised a synthesized representation of one specialized advance practice nursing role. More work is needed to further define the concept of the advance practice nursing, as well as its implementation on other cultures beyond this review. Based on this review, an international consensus regarding the definition of advance practice nursing and its subroles is possible.
In spite of a growing trend toward academic education and increasing numbers of "nursing experts" functioning as change agents in Germany, actual nursing experts as in the internationally described Advanced Nursing Practice (ANP) are scarce. Drawing from a ten-year experience in implementing the international concept, the University Hospital Freiburg (UKF), Germany, constitutes a notable exception, as it presently employs ten clinically practicing nursing experts. Based on this background of educating nursing experts, this presentation aims at describing the implementation of the nursing expert's role and its fit and conformance with the international ANP. A 3-stage Delphi design was used for interviewing all the nursing experts at the hospital (n = 10) about their expert opinions; in addition, all nursing managers (n = 7) as well as unit and team leaders (n = 49) were asked about their opinion to relevant functions and domains of nursing experts. The following clinical practice domains of nursing experts were identified: Direct patient care, patient education, support and supervision of nurses, maintenance and expansion of professional skills and knowledge of the nursing staff, counselling of managers, quality assurance and organizational development, theory to practice transfer, nursing research, maintenance of own professional skills and knowledge and continuing education, and publicity work. Additionally, a three-year nursing education, a longer lasting professional experience, a degree in nursing science or nursing education, and specialist skills in the respective area of expertise were identified as credentials for nursing expert practice. The nursing expert concept at UKF shows elements of the international ANP with similarities to the role of a Clinical Nurse Specialist.
This paper describes a participatory, evidence-based, patient-focused process for advanced practice nursing (APN) role development, implementation, and evaluation (PEPPA framework).
Despite the growing demand for advanced practice nurses, there are limited data to guide the successful implementation and optimal utilization of these roles. The participatory, evidence-based, patient-focused process, for guiding the development, implementation, and evaluation of advanced practice nursing (PEPPA) framework is an adaptation of two existing frameworks and is designed to overcome role implementation barriers through knowledge and understanding of APN roles and environments. The principles of participatory action research directed the construction of the new framework.
The process for implementing and evaluating APN roles is as complex and dynamic as the roles themselves. The PEPPA framework is shaped by the underlying principles and values consistent with APN, namely, a focus on addressing patient health needs through the delivery of coordinated care and collaborative relationships among health care providers and systems. Engaging environmental stakeholders as participants in the process provides opportunity to identify the need and shared goals for a clearly defined APN role. The process promotes increased understanding of APN roles and optimal use of the broad range of APN knowledge, skills, and expertise in all role domains and scope of practice. The steps for planning and implementation are designed to create environments to support APN role development and long-term integration within health care systems. The goal-directed and outcome-based process also provides the basis for prospective ongoing evaluation and improvement of both the role and delivery of health care services.
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