Daily practices of advanced practice nurses within a multi-professional primary care practice in Switzerland: a qualitative analysis.

BACKGROUND: The rising global population of older persons with chronic conditions demands new primary care models. Advanced practice nurses (APNs) can help meet that need. In Switzerland, APNs have only recently been introduced in primary care and little is known about their daily practice. This study aims to describe APNs' activities and general roles at four sites with multi-professional primary care practices in the Swiss cantons of Bern and Solothurn. METHODS: To study the practices of APNs at the study sites, we adopted a social constructivist perspective, lending methods from ethnographic field research. We interviewed, observed and accompanied participants over five months, generating rich data on their daily practices. The analysis followed Braun and Clarke's six-step thematic analysis process. RESULTS: The APNs' daily practices cover three main themes. Their core activities are working with expanded clinical skills and being on-site specialists for patients and their relatives. These practices are surrounded by net activities, i.e., taking care of patients in tandem with the physicians and regular visits in residential long-term care facilities. The outer activity layer consists of cohesive activities, with which APNs anchor and facilitate their role and catalyze further development of the care model. APNs tailor their expanded medical knowledge and nursing practice to maximize the value they provide in patient care. CONCLUSIONS: This study extends our knowledge of APNs' daily practice within a Swiss multi-professional primary care practice. Our results indicate competencies that need to be integrated in APN education and point out the high potential of APN integration in such primary care practices.

"Don't let the world become too small" ­ How patients with advanced cancer and their significant others cope with transitions during the last year of life. A qualitative study / «Die Welt nicht zu klein werden lassen¼. Wie Menschen mit einer Krebserkrankung und Angehörige Übergänge in den letzten Monaten bewältigen. Eine qualitative Studie

Background: In the last year of life, persons with advanced cancer and their significant others are affected by several transitions. They perform psychological adjustment processes during transformation. This requires strategies for patients and their significant others. Research in German about this theme is missing. Aim: We explored the experiences with illness management during transitions in the last year of life of patients with advanced cancer and their significant others. Method: In this qualitative study, we conducted structured interviews with five dyads, consisting of persons with Karnofsky Index ≥ 60 % and life expectancy of six to twelve months as well as their significant others. To interpret the interviews, we used qualitative content analysis according to Mayring. Results: The main theme "Don't let the world become too small" expresses that limitations diminished the lifeworld and the participants struggled against this process. This is revealed in three categories: "Being shocked by diagnosis ­ realigning again", "Bearing limitations and loss ­ finding new ways in daily life", "Living in uncertainty ­ holding out together". Conclusions: Patients and significant others live in changing lifeworlds caused by transitions. Health care professionals should be attentive and may gain deeper knowledge about transitions. Further research in German-speaking contexts will help to improve nursing care and psychooncological interventions.

Framework for Evaluating the Impact of Advanced Practice Nursing Roles.

PURPOSE: To address the gap in evidence-based information required to support the development of advanced practice nursing (APN) roles in Switzerland, stakeholders identified the need for guidance to generate strategic evaluation data. This article describes an evaluation framework developed to inform decisions about the effective utilization of APN roles across the country. APPROACH: A participatory approach was used by an international group of stakeholders. Published literature and an evidenced-based framework for introducing APN roles were analyzed and applied to define the purpose, target audiences, and essential elements of the evaluation framework. Through subsequent meetings and review by an expert panel, the framework was developed and refined. FINDINGS: A framework to evaluate different types of APN roles as they evolve to meet dynamic population health, practice setting, and health system needs was created. It includes a matrix of key concepts to guide evaluations across three stages of APN role development: introduction, implementation, and long-term sustainability. For each stage, evaluation objectives and questions examining APN role structures, processes, and outcomes from different perspectives (e.g., patients, providers, managers, policy-makers) were identified. CONCLUSIONS: A practical, robust framework based on well-established evaluation concepts and current understanding of APN roles can be used to conduct systematic evaluations. CLINICAL RELEVANCE: The evaluation framework is sufficiently generic to allow application in developed countries globally, both for evaluation as well as research purposes.

Prevalence and contributors to fatigue in individuals hospitalized with advanced cancer: a prospective, observational study.

BACKGROUND: Although fatigue affects over 75% of patients with advanced cancer, changes over time in symptoms and antecedents have not been described in the acute care setting. OBJECTIVES: To determine the prevalence, in patients with advanced cancer, of fatigue and anaemia on admission, describe strategies used to treat anaemia, observe changes in fatigue over ten days, and determine factors associated with fatigue. DESIGN: Prospective, observational study. SETTINGS AND PARTICIPANTS: In two Swiss tertiary care hospitals, a convenience sample of patients (N=103) was recruited at admission and followed up at days six (n=76) and ten (n=53). Patients were admitted because of new and/or worsening symptoms, deteriorating health status, or complications. They received measures aimed at symptom control and disease modifying interventions. METHODS: Clinical and sociodemographic data were collected on selected patients who were able to complete a test battery of validated measures. Assessment was undertaken on hospital admission and on days six and ten post-admission. FINDINGS: At admission, according to the suggested cut-off score of 43 for the FACIT-Fatigue scale, 87% of participants were experiencing cancer-related fatigue. Fatigue varied greatly within and among patients. Data on anaemia were available for 100 patients, of whom 62% were anaemic on admission. Severe and life threatening anaemia were mostly treated with red blood cell transfusions. Over time, fatigue decreased for patients who improved enough to be discharged (p<0.001) but not for those who withdrew from the study, most of whom did so due to worsening health. In multiple regression analysis, younger patients and patients with lower functional status, higher scores for depression, and more other anaemia-related symptoms experienced more fatigue. The variables examined explained 62% of variance in fatigue. CONCLUSIONS: Fatigue was common in hospitalized patients with advanced cancer and the majority were anaemic. Based on these data, monitoring and treating fatigue and anaemia over a ten-day hospital stay seem to be supported. The variable trajectories call for interventions carefully tailored to individual patients. The results should be considered as a first step to exploring fatigue in these patients.

Prevalence of symptoms, with a focus on fatigue, and changes of symptoms over three months in outpatients receiving cancer chemotherapy.

QUESTIONS UNDER STUDY: Prevalence of symptoms, with a focus on fatigue, and changes of symptoms were explored over three months in outpatients with lymphoma, lung, breast or colorectal cancer, receiving chemotherapy in the oncology outpatient clinic of a Swiss tertiary care hospital. METHODS: Prospective, descriptive design; symptom prevalence was measured at start of chemotherapy (T1), and one week prior to the third and fourth cycle (T2, T3). Included were patients starting chemotherapy, with expected survival of >3 months, irrespective of stage of disease. The Memorial Symptom Assessment Scale was used to assess 32 symptoms; fatigue was measured with the FACIT-Fatigue Scale (negative scale). Data were analysed using descriptive statistics and random-intercept regression models. RESULTS: 77 patients participated at T1, 58 and 50 at T2 and T3. Patients experienced on average 9.8, 14.4, and 13.7 symptoms, showing a significant increase over time. Lack of energy and feeling drowsy were most frequent. Symptom scores for lack of energy, changes in skin, pain, and feeling drowsy remained >2 over time (scale 0-4, higher scores = more symptoms). Fatigue mean scores were 36.3, 30.2, and 31.3, showing a significant increase of fatigue over time. Individual symptom trajectories varied widely within and among patients. CONCLUSIONS: High symptom prevalence at start of chemotherapy as well as over time and great variability in symptom experience call for an individual, systematic symptom assessment and management that does not focus solely on side-effects of therapy but includes disease-related symptoms to achieve satisfactory control of symptoms in outpatients receiving chemotherapy.

Symptom prevalence and changes of symptoms over ten days in hospitalized patients with advanced cancer: a descriptive study.

PURPOSE: This prospective study described symptom prevalence and changes of symptoms over ten days in patients with advanced cancer admitted to two Swiss tertiary care hospitals because of symptoms, deterioration of health status, or complications. METHOD: Prevalence, frequency, severity of and distress from 31 symptoms were assessed repeatedly with the Memorial Symptom Assessment Scale in 103 patients at admission, and on day six (n = 76) and ten (n = 53) of the hospital stay. Repeated measures regression models were used for analysis. RESULTS: The mean number of symptoms experienced was 13.0 (SD = 6.1) at admission, 9.7 (SD = 5.4) on day six, 9.3 (SD = 4.9) on day ten. Lack of energy was most prevalent (82% of patients) and most frequent, pain was most severe and distressing; symptom scores of all but 4 symptoms (weight loss, "I don't look like myself," vomiting, itching) were >2 on a scale from 0 to 4. Over time, the average number of symptoms decreased significantly for the whole group (P < .0001) and for patients discharged after day six (P = .006), but not for patients dropping out after day six due to worsening health status (P = .78). Individual trajectories showed that symptom prevalence varied greatly within and among patients. CONCLUSIONS: High symptom prevalence at admission, identification of areas in symptom management with the potential for improvement, and wide variability in symptom prevalence among patients call for comprehensive symptom assessment and individual treatment, especially in patients with a worsening health status.

[Reading nursing Literature in English: new inputs for practicing nurses]. / Fachenglisch für Pflegende: Aus der Praxis für die Praxis.

A prerequisite to providing evidence-based care is the ability to comprehend the nursing research literature, most of which is published in English. To facilitate this understanding, a course on "reading the research literature for evidence-based practice in English" was developed by an interdisciplinary team for staff nurses at the University Hospital Basel. The pilot course was offered to nurses who specialized in cancer care. It was led by the oncology Advanced Practice Nurse (APN) from the Department of Medicine. Research articles focusing on the management of chronic illness and cancer pain management were assigned and read. The course consisted of ten 90 minute lessons. The evaluation was designed to address the following questions: 1. Did participation in the course improve the oncology related knowledge of the nurses? 2. Did participation in the course improve the nurses' English language skills? 3. At what level of difficulty did the nurse participants perceive the course to be? 4. Were course participants able to use their newly acquired knowledge to teach their nursing colleagues on the ward? The course evaluation demonstrated that the 15 participants significantly improved their oncology knowledge through this process but that their English skills did not improve. The participants were able to present lectures on their wards based on the course literature, which were positively evaluated by their colleagues and the APN course leader. The participants perceived the course as being sophisticated but also effective at demonstrating the use of English-language research literature for one's own nursing practice.