This article describes an overview of the development and the implementation process of advanced practice nursing in Germany. It shows the first steps and legal perspectives of the speciality in Germany as well as one example of Advanced Practice Nurse (APN) role implementation at the University Medical Center in Hamburg-Eppendorf (UKE).
Academisation of nursing education
The academisation of nursing education in Germany gained in importance in 2012, at the latest with the announcement of the German Council of Science and Humanities. Due to demographic and epidemiological changes, the complexity of patient care will increase significantly in the future. Therefore, the German Council of Science and Humanities recommends an academisation rate in nursing care of 20% in complex areas [1]. In addition, the German Professional Association for Nursing Professions (Deutscher Berufsverband für Pflegeberufe, DBfK), the Swiss and Austrian Professional Associations issued a position paper on the definition, qualification, professional title and regulation of advanced practice nursing in 2013 [2].
However, Germany is still far away from achieving the academic rate of 20% in direct patient care or at bedside. In 2018, a national survey at German university hospitals determined the overall ratio of nurses with an academic degree in direct patient care with an average of 2.1% (standard deviation: 1.40; IC95: 1.36-2.76; minimum-maximum: 0.47-5.42%) [3].
Education and legal perspectives or prospects
In Germany, there are 2 ways of general nursing qualification. Usually, there is a non-academic, 3-year training, with specialisation in general care, children care or elderly care. The other way is a combined general qualification with a 4-year training and includes a bachelor's degree. Further, after general qualification, there is an option for a specialised qualification in e.g., intensive care, anaesthesia care or oncology nursing. With a master's degree, the nurses are able to work as an APN. In Germany, the APN title is not protected by law and the requirements for this title are not determinated [4]. Since there is no registration for caregivers in Germany, it is unknown how many nurses, especially with an academic degree, are working in the German healthcare system. Additionally, the payment for APNs in direct clinical care or bedside is not anchored in the collective agreement. This is the reason why every APN is paid individually in German hospitals, which is challenging in practice implementation.
Historical development
In the last few years, a lot of APN positions have developed in Germany, but there are still some hurdles that have to be overcome in the course of the development. A national survey of 500 nurse directors or chief nursing directors in 2018 revealed that the payment, the implementation into individual clinical structures and the design of the task profile of APNs are the 3 greatest challenges in the implementation of APN roles [5].
The first APN roles in Germany were developed approximately 20 years ago. The APNs at that time were named as “nurse experts”. One of the clinics with the longest experience in advanced nursing practice in Germany is the University Medical Center Freiburg. In 2008, the university conducted a Delphi designed survey to describe the implementation of their APN roles, tasks and their alignment with the international description of the APN role. Following nursing tasks have similarities with the role of a Clinical Nurse Specialist [6]:
- direct clinical practice;
- 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 their own professional skills, knowledge, continuing education;
- publicity work.
It turns out that the APN tasks described can be found in many other APN concepts, such as the one in the University Medical Center Hamburg-Eppendorf (UKE). Most of the APN concepts contain the core concept of APN tasks based on Ann Hamric's APN core competencies, which consists of direct clinical practice, guidance and coaching, consultation, evidence-based practice, leadership, collaboration and ethical decision-making [7].
Examples of APN implementation at the UKE
Since 2014, the UKE has been working intensively on academisation of nursing education. The UKE developed a competency model, which classifies all nursing qualifications in patient care in 2014. This was not only because the first bachelor students started to study, but also because the time had come to actively shape the academisation of the nursing professions. The aims of the competency model are to be able to present all vocational qualifications in a transparent manner and to integrate bachelor and master graduates in direct clinical practice. Since 2014, there has been a steady increase in the number of academically qualified nurses at the UKE. In 2021, the rate of academic nurses in direct patient care is 6.28%, which is 3 times the national average.
In addition to the development of the competency model, a nursing journal club and an APN network were set up to maintain the scientific competences of academically qualified nurses.
At the UKE, we understand APN as care experts with a master's degree and at least 6 years of professional experience as a nurse, ideally in their respective specialisation. The PEPPA framework [8] is always used to develop new APN roles or for the evaluation of existing APN roles.
Currently, there are hardly any pre-existing APN roles in practice, so almost all roles have to be newly developed. The locations in which the implementation of an APN could be useful are discussed with nursing scientists and nursing managers. This is followed by a literature review and a secondary data analysis to identify patient groups that need an APN. After a suitable nurse with a master's degree has been found, or a nurse who would like to complete the master's program, individual role development will begin. The students as well as the nurses with a master's degree receive support and guidance from a nursing scientist from the nursing directorate during the entire role development. To help APNs find their way around the ward in their new role, we have developed basic tasks for APNs. They consist of the Hamric's model of APN core competencies and the UKE competency model. The basic tasks include the following areas: direct and specialised patient care, management, assurance and evaluation of excellent nursing specialist development, specialised support and advice, application of scientific methods and tasks in research and teaching, training, further and/or continuing education. The basic tasks are also used to evaluate the APN roles in order to present development potential in the corresponding areas.
In 2021, we have 11 APNs practicing, with specialisations in oncology nursing, critical care, delirium management, neurology/stroke, ophthalmology, heart valve diseases and end of life care. All of them have a master's degree and a minimum of 6 years of nursing experience in their specialisation.
APN for chronically ill oncology patients
One example of APN role implementation in oncology nursing at the UKE is the specialisation for chronically ill oncology patients. As part of the APN role development in the mixed oncology department, the patient group that is most likely to require complex nursing care was identified together with the nursing management, the ward management, the nursing team and the APN. In addition, secondary-controlling data were analysed to find out, for example, which patients are most frequently readmitted as an emergency case, have most complications or the longest hospital stay. After defining the patient group, the basic tasks of APNs were used to develop the specific activities for providing care to the patient group. These tasks were in turn prioritised for implementation to ensure a stepwise and an efficient implementation.
One of the most important activities of the APN for the care of patients with chronic oncologic diseases lies in the implementation of care for patients receiving CAR T-cell therapy. In CAR T-cell therapy, healthy T-cells are removed from the patient, genetically modified and then retransplanted. Ideally, these cells can recognize tumor cells and destroy them. Due to the mode of action of this new type of therapy, increased attention and expert knowledge are required from the nursing side so that complications can be recognised as soon as possible. These include, in particular, symptoms of cytokine release syndrome. In addition, both the patient and his relatives and the nursing staff on the ward need advice and support, which is carried out by the APN. It is known that it is particularly important to advise patients on symptom management so that complications can be identified and treated at an early stage [9].
Furthermore, the APN conducts nursing rounds to gather information between additional complex patients, the patient and the nursing team, in order to design a nursing process as optimal as possible for the individual patient. She is also responsible for ensuring that the agreed interventions are evaluated and adjusted as necessary.
The APN role described here is still evolving, but patient responses already indicate that the APN is perceived as an expert.
Future perspectives
Advanced nursing practice is a concept that has become more and more popular in recent years. The Covid-19 pandemic and nursing shortage highlight the importance of having direct patient care experts who can support their colleagues with their expertise.
However, further development also faces major hurdles that need to be overcome. These include the regulation of APNs, the definition of specific tasks and payment in the tariff structure in Germany.
Recognition of APNs within their own profession must be further promoted and publicised. The benefits of patient care and the patient outcomes must be documented and made visible. To this end, further research is needed to prove the effectiveness of advanced nursing practice.■