Promoting and hindering conditions for the implementation of advanced practice nursing in primary care in Germany and Brazil

Background and state of research: Primary care (PC) has to adapt to the increasing number of patients with complex care needs. Advanced Practice Nursing (APN) can be a suitable strategy to enhance PC services, improve care quality and strengthen health promotion. It also bears the opportunity to transfer certain clinical tasks from general practitioners (GPs) to nurses, allowing physicians to focus on patients with complex medical needs. APN implementation, however, faces challenges, for example shortages of nurses and a lack of recognition of nurses’ competences by other health professionals and patients. Research question and objectives, hypothesis: This study aims to comparatively investigate conditions that facilitate and hinder the development and implementation of APN roles and tasks in PC in Germany and Brazil. Both countries face major challenges but also comprise facilitating conditions. The comparative analysis of these conditions can support learning processes and innovation in PC. Method: A cross-country comparative qualitative study in Brazil and Germany was conducted. A total of eight focus groups were carried out; for each country one group with stakeholders at the federal level, one group at the regional level, and two groups with GPs and PC nurses. Data was analysed following thematic coding process. Results: Participating experts see facilitators and obstacles at the (1) regulatory and (2) practitioner level: (1) They acknowledge the significance of model projects that pilot APN roles in PC. However, they miss basic legislation for APN implementation and criticize lacking financial incentives for APN development. Infrastructural challenges hinder the implementation of APN in both countries: Participants from Germany see a general shortage of nurses as a crucial barrier for developing extended nursing roles. Experts from Brazil stress that a lack of technical infrastructure like medical equipment prevents nurses from performing extended tasks such as diagnostic exams. (2) The participants denote current strengthening of graduate education in both countries as a chance, they, however, criticize lacking career paths for APNs. Nurses’ ability to act autonomously within their scope of practice is considered crucial for the implementation of APN in PC. Experts from Brazil see it as a strength, that APN could be implemented step-by-step by advancing tasks of already academically educated nurses e.g., via protocols. In Germany, new models of care would be needed to pave the way for APN implementation in PC. For the Brazilian participants, key for the implementation is improving communication and cooperation in PC teams. For the German participants overcoming the hierarchy between physicians and nurses is crucial. Discussion: Our study results indicate similar challenges for APN implementation in PHC in both countries. Future research should focus especially on necessary resources to transfer model projects for APN implementation in PC into regular practice. Implication for care: Implementation of APN roles in PC needs to be supported by an ongoing dialogue among health policy actors and professionals’ representatives focusing on complementing competences of APN and physicians. Funding: Other funding; 57598578