Bern University Hospital

Direktion Pflege/MTT

Nursing Research Unit

www.inselgruppe.chwww.nursing.unibas.ch

Advanced Practice Nurses as

Disruptive Innovation –

Also for Switzerland?

Michael Simon, Sabina De Geest

Disruptive innovation?

vs.

https://www.flickr.com/photos/janitors/15523824899

Solutions needed

The Lancet 2015 386, 743-800DOI: (10.1016/S0140-6736(15)60692-4)

Population

Costs

5

+25%

Avoidable Hospitalizations from nursing homes

6

Hospital admissions in

Switzerland 2013

65 years or older

N=21’114

Own analysis

1.6

1.8

1.9

1.9

2.1

2.3

2.4

2.9

3.1

4

4.4

4.6

6.5

8.8

0 2 4 6 8 10 12

COPD

Intracranial injury

Affective disorders

Urinary tract infections

Fracture of lower limb

Other fractures

Fracture of upper limb

Osteoarthritis

Acute cerebrovascular…

Septicemia

Congestive heart failure

Pneumonia

Organic mental disorders

Fracture of neck of femur

Ambulatory

care sensitive

condition

Falls & trauma

Advanced Nursing Practice (ANP)

in Switzerland

UNIVERSITY OF BASEL

Advanced Practice

Nurses (CH)

Anja Ulrich, MSN

Giovanna Jenni, MSN

Concept Palliative Care

Nursing home, Laupen

Dunja Nicca, PhD

HIV-careAgnes

Kocher,

MSN

System

Sclerosis

Geriatrics,USB

Primary care in CH

ANPs are being introduced as part of new models of care

o Medizentrum Schüpfen

o Medix Zürich

o Praxisgemeinschaft Bauma

o Praxis rundum Onkologie

9

What are Advanced Practice Nurses?

11

Clinical Nurse Specialist

(CNS)

Nurse Practitioner

(NP)

Training MSc MSc incl. 600 hrs. clinical training

What Specialty areas within nursing

practice: defined by

population, setting,

disease/health problem

Primary care or specialized area

(family health, geriatrics,

pediatrics etc.) collaboratively

with physicians and other

health professions

Setting • Hospitals

• Long-term care

• Community health

• Ambulatory health

• Long-term care

• Hospitals

Scope In addition to direct patient

care, CNS have a system-

focused role as:

• Clinical expert

• Educator

• Consultant

• Evidence-based change

agent

• take health histories, perform

physical exams,

• assess, treat, and evaluate

acute and chronic illness

• order / interpret tests

• prescribe/ manage

medications

Legal, policy context

Education

Health care needs of population

Drivers of ANP development

in various countries

Workforceissues

Outcomes research ANP

De Geest et al. Introducing Advanced Practice Nurses / Nurse Practitioners in health care systems:

a framework for reflection and analysis. Swiss Med Wkly 2008; 138(43-44): 621-628.

Practice patterns

ANPs – increasing around the world

13

C.B. Maier, L.H. Aiken, R. Busse (2016) Nurses in advanced roles in primary

care: policy levers for implementation. OECD working papers (forthcoming)

First group of Master of Sciencein Nursing @ UNIBAS in 2004

Already ANP education in Switzerland

• Since 2004 at UNIBAS

• Since 2012 ANP+ with 600 hrs.

clinical practice at UNIBAS

• Since 2015 at Kaleidos

• In preparation at UNIL

• >350 MSc-trained nurses from

UNIBAS, UNIL and UAS

APNs provide high quality care

Martinez-Gonzalez et al. Plos One 2014; 9: e89181

11 RCT, 30247 patients

systolic blood pressure

• No significant differences in view of

• Diastolic blood pressure

• Total cholesterol

• HbA1c

• Quality of studies suboptimal (bias)

• Other 32 clinical parameters not included in meta-

analysis:

• Less then a fifth favored nurse-led care

• 25 parameter no difference

Martinez-Gonzalez et al. BMC Health Services Research 2014; 14: 214

22 Studies

Meta-analysis (outcomes studied 3 times or more):

• patient satisfaction

• hospital admission

• mortality

• Effects on QOL and costs were difficult to interpret due to heterogeneity of

methods applied

• Quality of studies suboptimal (bias)

• Moderator analysis shows importance of careful interpretation of findings.

• 43 papers involving 28 studies

• 15 studies reported in multiple papers

• 65% of studies occurred after 2000

• Country of origin (US , UK, Netherlands, etc.)

• Risk of Bias (~60% is high or moderate)

• Quality of Economic Analyses (~87% is poor)

Cost-Effectiveness of CNS and NP Roles

(Donald et al., 2014)

Nurse Practitioners (n=18 RCTs)

Health

Status

Quality

of Life

Quality

of Care

Patient

Satisfaction

Rehosp-

italizationCost

Length

of Stay

Improved 3 1 4 8 1 3

Decline 2

No

Difference13 8 2 4 4 5 5

Clinical Nurse Specialists (n=25 RCTs)

Health

Status

Quality

of Life

Quality

of Care

Patient

Satisfaction

Rehosp-

italizationCost

Length

of Stay

Improved 7 2 1 6 6 7 6

Decline 1 1

No

Differenc

e

14 9 2 3 5 9 9

Evidence for Switzerland

INTERCARE

• “Nurse-led models of care in Swiss nursing homes:

improving interdisciplinary care for better resident

outcomes”

• 2017-2020

• SNF funded

• Research group: M. Simon, F. Zúñiga, S. De Geest, D.

Nicca, A. Zeller, R. Kressig, C. Di Pietro, N. Wellens, M.

Desmedt.

22

INTERCARE 2017-2020

23

1. Development of a ‘Swiss nurse-led interprofessional NH care model’

2. Implementation and evaluation of the ‘Swiss nurse-led

interprofessional NH care model’

Schweizer Modell zur

pflegegeleiteten inter-

professionellen Versorgung

in Pflegeheimen

Prototyp: Pflegegeleitete interprofessionelle Versorgung in Pflegeheimen

Stakeholders

InternationaleEvidenz

RAND/UCLA

Review

Interviews

7

8

3

4

5

6

Anpassung

1

2

Kontrolle

Stepped-wedge design

AH

AH

AH

AH

AHAH

A1

A2

B1

B2 B3

Machbarkeit

Akzeptanz

Barrieren & Unterstützer

Kosten

I m plem tieru ngs-

ergebnisse

Wartezeiten

Bewohnerzentrierung

Service Ergebnisse

Vermeidbare

Spitalaufenthalte

Qualitäts Indikatoren

Lebensqualität

Bewohnerzufriedenheit

Bew ohner Ergebnisse

6 Mon.

Bewohner & Angehörige

Interviews

9

10

11

12

12 Mon.3 Mon.

Intervention

Phase B ( 2 0 1 8 - 2 0 2 0 )Phase A ( 2 0 1 7 )

PEPPA+ Fram ew ork

(Bryant-Lukosius et al., 2004 & 2016)CFI R- I m plem ent ierungsm odell

(Damschroder et al., 2009)

24

You decide!

Key points

• APNs is a key element of new models of care

• Nurse-led models of care are on par with usual care in terms

of clinical outcomes, patient satisfaction and cost.

• APNs are part of an interprofessional team – APNs and

physicians work together.

• We need an interprofessional discussion about APNs in the

Swiss Healthcare System.

25