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Corresponding author. Dr. Manela Glarcher, MSc. BSc., RN, Research Associate, Institute of Nursing Science and Practice, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria.
Internationally, Advanced Practice Nurses (APN) are associated with improvements when measuring results in health care. Advanced Nursing Practice (ANP) refers to an extended nursing care with the aim of meeting the changing conditions in health care systems by providing evidence-based practice. APN outcomes are the endpoints of nursing interventions based on clinical experience, scientific knowledge, and practical skills. Due to the challenges in health care systems, Advanced Practice Nurses have become well established internationally in various fields.
Problem
In Austria, the first nurses are currently trained in Advanced Nursing Practice on a master's level according to the International Council of Nurses core curriculum (ICN). However, national implementation and evaluation strategies are still missing.
Objective
The aim of this short report is (i) to show the current situation of APNs in Austria, and (ii) to underline the importance of measuring APN outcomes in implementing this role for future developments in health care.
Method
A literature search was conducted in CINAHL (Cumulative Index to Nursing and Allied Health), PubMed, and the Cochrane Library in the period 09/2019 to 01/2020.
Results
With the help of APNs and coordinated, holistic, patient-centered care, a higher quality of care for different patient groups is clearly evident. The cost-effectiveness and the positive experience of both patients and nursing staff have been demonstrated in international studies. In particular, the guidance and educational skills of APNs have been shown to improve health outcomes in vulnerable population groups.
Conclusion
With regard to the implementation of APNs in the health care system, more focus is needed on the measurement of outcomes in nursing research. Outcome research has been shown to help identify the unique effect of APNs in patient care and to highlight the health-related improvements through Advanced Nursing Practice for health policy and further developments in the health care system.
Zusammenfassung
Hintergrund
International werden Advanced Practice Nurses (APNs) mit Verbesserungen bei verschiedenen Ergebnissen in der Gesundheitsversorgung in Verbindung gebracht. Advanced Nursing Practice (ANP) bezieht sich auf eine erweiterte, spezialisierte Krankenpflege mit dem Ziel, den sich ändernden Bedingungen in den Gesundheitssystemen gerecht zu werden und eine evidenzbasierte Pflegepraxis zu sichern. APN-Outcomes verdeutlichen die Endpunkte pflegerischer Interventionen, die auf klinischer Erfahrung, wissenschaftlichen Erkenntnissen und praktischen Fähigkeiten der spezialisierten Pflegepersonen basieren. Bedingt durch die Herausforderung in den Gesundheitssystemen haben sich APNs international in verschiedenen Bereichen gut etabliert.
Problemstellung
In Österreich werden derzeit die ersten APNs auf Master-Niveau gemäß den Empfehlungen des International Council of Nurses (ICN) ausgebildet, jedoch fehlen nationale Umsetzungs- und Evaluierungsstrategien.
Ziel
Ziel dieses Kurzberichts ist es, 1.) die aktuelle Situation der APNs in Österreich aufzuzeigen und 2.) die Bedeutung der Messung von APN-Ergebnissen bei der Umsetzung dieser Rolle für zukünftige Entwicklungen im Gesundheitswesen zu verdeutlichen.
Methode
Zur Erfassung von APN-Ergebnissen wurde eine Literaturrecherche in CINAHL (Cumulative Index to Nursing and Allied Health), PubMed und der Cochrane Library im Zeitraum 9/2019 bis 1/2020 durchgeführt.
Ergebnisse
Mithilfe von APNs und einer koordinierten, ganzheitlichen, patientenzentrierten Pflege wird eine höhere Qualität in der Versorgung von unterschiedlichen Patientengruppen deutlich. Die Kosteneffektivität und auch das positive Erleben von Patient*innen und Pflegepersonal wurden in internationalen Studien nachgewiesen. Insbesondere die Beratungs- und Schulungskompetenzen von APNs verbessern nachweislich die Gesundheitsergebnisse in vulnerablen Bevölkerungsgruppen.
Schlussfolgerung
Im Hinblick auf die Implementierung von APNs im Gesundheitssystem sollte die Ergebnismessung in der Pflegeforschung verstärkt fokussiert werden. Die Outcome-Forschung trägt nachweislich dazu bei, den einzigartigen Effekt von APNs in der Patientenversorgung zu identifizieren und die gesundheitsbezogenen Verbesserungen durch Advanced Nursing Practice für die Gesundheitspolitik sowie weitere Entwicklungen im Gesundheitswesen deutlich zu machen.
Internationally, the complexity of health care, demographic change, an increase in chronic diseases, cost pressure, and the increased call for patient safety strategies are currently challenging all health care professionals [
L. Ash, C. Miller, Interprofessional Collaboration for Improving Patient and Population Health, In: S.M. Denisco, A.M. Barker (Eds.), Advanced Practice Nursing Essential Knowledge for the Profession, third ed., Jones & Bartlett Learning, Burlington, MA, 2016, pp. 123-147.
]. Health care in Austria will also face major challenges in coming decades. The retirement of one third of all family doctors will lead to a serious reduction in the number of medical staff. Data from Statistics Austria demonstrate that in 2018 66.4% of all physicians were 50 years or older. The analysis of hospital records shows a nationwide decline of 13.8% of all hospital beds since 1985 and a reduction of inpatient stays in acute care by 23% in the last 20 years [
]. Among the OECD countries, Austria shows one of the highest hospitalization rates due to avoidable chronic diseases such as asthma, chronic obstructive pulmonary disease (COPD), or diabetes [
OECD/European Observatory on Health Systems and Policies, State of the Health in the EU, Austria: Country Health Profile 2019. https://www.oecd-ilibrary.org/social-issues-migration-health/austria-country-health-profile-2019_fe6121d2-en, 2020.(accessed 4 June 2020).
]. Based on these data, in future there will be a reduced number of doctors available to care for an increasing number of chronically ill patients.
Another major challenge for the Austrian health care system is the often unhealthy lifestyle in the population, which is due to increased tobacco and alcohol consumption. In 2014, a total of 24% of adults in Austria stated that they smoke daily, which puts Austria three percentage points above the EU-28 average [
]. These findings highlight a need for improvement in the prevention and early detection of diseases as well as in the establishment of measures to develop health literacy in the Austrian population. A possible solution is the training of nurses in advanced knowledge and skills [
]. Among other things, Advanced Practice Nurses can make a significant contribution to the development of health literacy among the population, in the context of preventive health care and disease prevention, but also in the implementation of disease management programs for chronically ill people. The expertise, education, and skills associated with these nursing roles are diverse and context sensitive. On a global level, there is a variety of academic programs addressing the education in Advanced Nursing Practice (ANP). The International Council of Nurses (ICN) uses the following definition:
“A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice [
International Council of Nurses (ICN), NP/APN Network, Definition and Characteristics of the Role. https://international.aanp.org/Practice/APNRoles, 2001-2020.(accessed 29 May 2020).
Advanced Practice Nursing comprises the terms Advanced Nursing Practice (ANP) and Advanced Practice Nurse (APN) as well as their social, professional and political framework. Advanced Nursing Practice (competence level) explains the skills and competencies of an Advanced Practice Nurse (role) [
] and varies fundamentally from traditional nursing practice through its different definition, other characteristics, fields of work and training requirements [
APNs can efficiently and effectively address the challenges of accessible, safe and affordable health care globally and improve patient health outcomes [
International Council of Nurses (ICN). GUIDELINES ON ADVANCED PRACTICE NURSING 2020. https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf, 2020.(accessed 5 June 2020).
In Austrian nursing practice, APNs have already entered the health care system and are working in various areas of nursing care. Occupational fields are for example specialized care for people with dementia, stroke, or diabetes in hospitals in Upper Austria, Salzburg, or Styria. Nevertheless, there is no specific job description in Austria and no official job title or professional recognition. APN skills and job profiles depend on the commitment and organizational opportunities of individual health care executives. The assessment of APNs on health outcomes is mostly based on the individual initiative of these pioneers and is not accessible nationally. However, as is also evident in international study results, this proof of effectiveness seems particularly relevant to demonstrate the importance and positive contribution of APNs to health care outcomes [
]. Nurses and health care professionals have an important role in measuring outcomes, as they are responsible for the performance of professional care services. In most cases, activities of APNs that lead to an impact on the health status of patients or the health system are not systematically recorded or associated to care [
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
The purpose of this short report is firstly to highlight the current situation of APNs in Austria and secondly to underline the importance of measuring APN outcomes in the implementation of this role for future developments in health care.
Methods
A literature review was used in this short report. CINAHL (Cumulative Index to Nursing and Allied Health), PubMed, and the Cochrane Library databases were searched from 09/2019-01/2020. Papers were included if they described health care outcomes, were published in English between 2010 and 2020, and were focused on Advanced Nursing Practice or Advanced Practice Nurse.
Education of APNs in an international context
The development of APN roles started 40 years ago in the United States. Despite this long history, there is no uniform understanding of the APN role worldwide. Moreover, there are great differences in the regulation of APNs and their training, licensing, and accreditation requirements. Part of the difficulty arises from the fact that roles are operationalized in very different ways around the world and that there are countries where two or more roles with different requirements and regulations can coexist. An international study identified 52 different APN roles in 26 countries all over the world. In 25, a master degree was the educational requirement. In the majority, the role of nursing with advanced practice covers an extended practice area that traditionally belonged to physicians [
]. The American Association of Colleges of Nursing (AACN) distinguishes the terms Advanced Nursing Practice (ANP), Advanced Practice Registered Nurse (APRN), and Advanced Practice Nurse (APN) for any intervention in health care and nursing, which has shown to affect the health outcome of individuals or groups. These interventions may include direct patient care, care management for individuals and/or groups of patients, health care management, and the development/implementation of health care delivery strategies. The conceptual definition focuses the patient-centered application of professional skills to improve health outcomes for patients and populations in a specialized clinical area [
American Association of Colleges of Nursing (AACN), AACN Position Statement on the Practice Doctorate in Nursing. https://www.aacnnursing.org/DNP/Position-Statement, 2004.(accessed 4 June 2020).
]. A theory-based conceptualization seems to be important in understanding the origin of Advanced Nursing Practice, both within the nursing profession, and in communicating with patients and other stakeholders. In general, stakeholders must be aware about the concept of APN care and its impact on health outcome as well as on the optimization of the processes within the health care system. Therefore, a consensus is necessary to clarify fundamental concepts and models in APN [
]. In the literature, several models and theories refer to Advanced Practice Nursing. One of them is the Consensus Model on Advanced Practice Registered Nurse Regulation (APRN) [
American Association of Colleges in Nursing (AACN), APRN Consensus Model. https://www.aacnnursing.org/Education-Resources/APRN-Education/APRN-Consensus-Model, 2008.(accessed 5 June 2020).
], based on the APRN Consensus Work Group of 2008, which distinguishes four professional roles:
•
The Certified Registered Nurse Anesthetist (CRNA),
•
the Certified Nurse-Midwife (CNM),
•
the Clinical Nurse Specialist (CNS),
•
and the Certified Nurse Practitioner (CNP).
The term Advanced Practice Registered Nurse (APRN) refers to all four roles. APRNs are educated in one of the four roles and in at least one of six population foci: Family/individuals across the lifespan, adult-gerontology, pediatrics, neonatology, women's health/gender-related, or psych/mental health [
American Association of Colleges in Nursing (AACN), APRN Consensus Model. https://www.aacnnursing.org/Education-Resources/APRN-Education/APRN-Consensus-Model, 2008.(accessed 5 June 2020).
]. The Certified Registered Nurse Anesthetist (CRNA) is qualified to provide the full spectrum of individual anesthesia care and anesthesia-related care in diverse settings. The Certified Nurse-Midwife (CNM) provides primary health care services for women in hospitals, birth centers, or at home. The Clinical Nurse Specialist (CNS) offers care across the wellness-illness continuum, in which direct primary and acute care is provided in various health-care settings. Certified Nurse Practitioners (CNP) are trained to diagnose and treat patients independently [
American Association of Colleges in Nursing (AACN), APRN Consensus Model. https://www.aacnnursing.org/Education-Resources/APRN-Education/APRN-Consensus-Model, 2008.(accessed 5 June 2020).
Identified core competencies in Hamric's integrative model of APN are guidance and coaching, counselling, evidence-based practice, leadership, collaboration, and ethical decision-making [
]. These competencies were also included in a position paper, which was developed in the year 2011 in cooperation with the association of nursing in Austria, Germany, and Switzerland as core competencies for APN in German-speaking countries [
In Austria, the development of the nursing profession is characterized by a late academization. First initiatives to educate nurses at university level started in the 1980s resulting in a few, yet not regularly offered courses. Between 2004 and 2007, the first nursing science curricula were developed at the universities of Graz, Hall in Tyrol and Salzburg in accordance with the guidelines of the Bologna Declaration. However, most degrees did not lead to a primary professional qualification in nursing [
]. Until 2016 most nurses were still trained in hospital-based nursing schools in a three-year diploma course. A fundamental change occurred the year 2016 as the professional training of nurses in general care was transferred from nursing schools to Universities of Applied Sciences. The main objectives of the reform of the Health and Nursing Care Act (GuKG) include competence orientation instead of action orientation, the distribution of the workload among different occupational groups, increasing the number of nursing staff and making the nursing professions more attractive in order to attract young people to the profession and keep those who have already been trained in the profession (4). The current model of care defines three groups of nursing professionals:
•
the registered nurse in general care (DGKP 4,600 hours of training),
•
the specialized nurse assistant (PFA 3,600 hours of training),
•
and the nurse assistant (PA 1,600 hours of training) [
Bundeskanzleramt, Bundesgesetz über Gesundheits- und Krankenpflegeberufe (Gesundheits- und Krankenpflegegesetz – GuKG). https://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen&Gesetzesnummer=10011026, 2020.(accessed 4 June 2020).
Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz, Gesundheitsberuferegister, Öffentliches Register. https://gbr-public.ehealth.gv.at/2020 (accessed 4 June 2020).
]. In 2012, the Austrian Association of Advanced Nursing Practice (AAANP) was founded to promote ANP in Austria and to participate in its implementation and further development [
]. Currently, there is no legal regulation concerning the training of APNs, which is why different education programs are offered at Universities of Applied Sciences and Universities. Advanced Nursing Practice programs have been successfully implemented at three Universities of Applied Sciences (Campus Vienna, Krems, and Upper Austria) and two private Universities (PMU - Paracelsus Medical University, Salzburg and UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol).
In addition, initiatives for recording health outcomes in Austria have been formulated with the aim of continuously improving the public health system, mostly starting from government agencies, health insurance companies, and health care institutions. National strategies based on the Austrian health plan (Österreichische Rahmengesundheitsziele, R-GZ), include the development of regular, systematic, and internationally comparable measurements of health system outcomes, in particular the effects of health promotion, prevention, curation, as well as long term and palliative care. A panel of experts developed a measurement and comparison concept for calculating outcomes in the health care system that allows outcome-related statements which are based on the performance of the health care system. The concept currently comprises around 40 health care indicators including items such as post-operative complications, but for which no data collection is currently available. Outcome indicators for palliative and long term care were also integrated [
Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz, Outcome-Messung im Gesundheitswesen basierend auf dem Mess- und Vergleichskonzept. https://primaerversorgung.org/wp-content/uploads/2020/01/2018_Outcome-Messung-im-Gesundheitswesen.pdf, 2017 (accessed 4 June 2020).
]. However, it does not include nurse-sensitive or APN outcome indicators.
Outcomes in Advanced Nursing Practice
Worldwide structural changes in health care facilities and expanding health care costs make the examination of innovative, cost-effective approaches to health care indispensable [
]. A greater emphasis on the provision of quality care and the promotion of patient safety, regulatory requirements for health facilities to demonstrate the effectiveness of care, as well as changes in the organization, delivery and financing of health care led to an increased focus on outcomes of health care [
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
]. Outcome measurement, as an area of health research, focuses on the end results of patient care. Outcome measures need a clear conceptual and operational definition for the calculation of the outcome indicators [
]. A number of outcome measurements and role impact models have been proposed. The majority of them evolved from the original quality of care framework proposed by Donabedian, in which structure and process directly influence the outcomes [
in: Mateo M.A. Foreman M.D. Research for advanced practice nurses From Evidence to Practice. second ed. Springer Publishing Company,
New York2014: 375-394
] published a conceptual model designed to facilitate the evaluation of nursing practice in acute care settings. Conceptual models serve to guide all participants towards the entire process and not only towards the description of individual phenomena. Their model includes three components, namely structure (patient, APN, organization), process (APN role components, role enactment, role functions), and outcomes (goals and expectations of the APN).
Core Outcome Sets (COS) are another way to measure outcome. COS represent a minimum data set that must be measured and reported either in clinical studies or in routine care. These outcome sets are also used in routine care, clinical trials and other scientific projects, but do not use a randomized study methodology (COMET). The main benefit of COS is an easier comparison of different outcome measures [
In nursing research different outcome indicators can be used to evaluate how nursing has changed the health status of patients. Indicators are regarded as quantitative evaluation instruments that provide information on the degree of previously defined quality objectives [
]. Kleinpell used care related (e.g. cost of care, time to readmission, time spent with patients), patient related (e.g. return to work, functional status, knowledge), or performance related outcome measures (e.g. technical quality, APN job satisfaction, adherence to best-practice guidelines) [
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
International studies in various care settings determine that APNs have significant potential to improve outcomes for patients, staff and professionals by maximizing health and quality of life through coordinated, holistic, patient-centered care [
]. In addition, the value of APNs is particularly evident in dealing with patients with complex needs, such as those arising from the effects of cancer treatment or postoperative complications e.g. in colorectal and stoma care (29). Improved patient and staff experiences can be reported in adolescent oncology patients. APNs provide clinical expertise, experience, and continuity in care processes, either within clinical teams or in health-related groups [
Role of the Advanced Nurse Practitioner Within Teenage and YOUNG Adult Oncology. What is the Impact on Patient and Staff Experience of a New Nurse Practitioner Role to a Teenage and Young Adult Service?.
J Adolesc Young Adult Oncol.2019; 8 (https://doi.org/10.1089/jayao.2019.0020): 668-673
]. Advanced Practice Nurse's expertise can be used to manage chronic diseases. For example, in family care setting to cope with the burden of symptoms of Asthma patients [
In adult risk patients surviving from pediatric malignancies, a distance-delivered (via mail and telephone) care intervention significantly increases the proportion of at-risk survivors who complete cardiomyopathy screening [
]. The APN telephone intervention as a low cost initiative has also proven to be an effective means of ensuring continuity of care for vulnerable groups, especially at a time of major budget cuts affecting health services. For example, low-income first mothers with problems of access to health care, language barriers and limited social support after the birth of healthy, full-term infants were successfully supported through APN telephone contacts [
]. Coaching and counseling by APNs can be a useful strategy to help patients with various cancers to break down attitudinal barriers to cancer pain treatment and to better manage their cancer pain. By using motivational interviewing techniques, advanced oncology nurses can help patients to develop an appropriate treatment plan to reduce pain and other symptoms [
In home care, it is shown that the advisory competence of APNs is particularly suitable for chronically ill elderly people in order to support them in leading as independent a life as possible [
]. In community-based health care, the APN intervention has been used to promote adherence to HIV and psychiatric treatment schedules to improve the viral load of people with HIV and severe mental illness [
]. Another study in a home setting illustrates the effectiveness of a low-intensity exercise protocol supervised by an advanced nurse in improving health-related quality of life (HRQOL), physical fitness and left ventricular ejection fraction (LVEF) in older adults after discharge from hospital with a diagnosis of cardiovascular disease [
]. The effectiveness of APNs can also be demonstrated in relation to complex chronic wounds in the care of patients with venous ulcers. The APN intervention included training and advice to clinical nurses on the proper management of injuries and the use of compression therapy. This intervention has been shown to improve the continuity of care and to optimize the resources used [
Current and future challenges in the health care system in Austria require a rethinking of the tasks and traditional roles of specific professional groups in the health care system. The implementation of APNs offers an opportunity to meet these challenges in different care settings, which has been proved by international study results [
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
]. First activities of Universities and Universities of Applied Sciences in Austria focus on teaching of nursing skills and the theoretical development of task profiles in all settings of nursing. The combination of clinical practice and nursing research enables an evidence based, high quality patient care. However, a clear understanding of the role of an APN is required from all stakeholders. Based on the model of care in Austria, a consensus concerning a theory-based conceptualization of APNs should be implemented and core competencies must be defined. To evaluate the effectiveness of APN intervention, measurement of APN specific outcomes based on models like the Nurse Practitioner Role Effectiveness Model [
]. In order to accurately measure outcomes, it is necessary to identify and select indicators, and develop appropriate measuring. A large number of indicators, which demonstrate the effectiveness of APN, have been reported in the international literature.
For many health care institutions, effectiveness means financial results such as cost-efficiency. However, a variety of other outcome indicators, documented in international studies, can be monitored, which demonstrate the positive contribution of APNs to health care results [
]. Nurses and health care professionals have an important role in measuring outcomes, as they are responsible for the performance of professional care services. In most cases, activities of APNs that lead to an impact on the health status of patients or the health system are not systematically recorded or associated to care [
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
Considering the implementation process of APNs, it can be summarized that outcome assessments should be seen as an essential part of all nursing activities which illustrates the positive impact of advanced nursing skills on the whole health care system.
Conflicts of interest
The authors declare no conflicts of interest.
CRediT author statement
Manela Glarcher: Conceptualization, Methodology, Writing- Original draft preparation.
Katharina Lex: Writing- Original draft preparation, Writing- Reviewing and Editing.
References
L. Ash, C. Miller, Interprofessional Collaboration for Improving Patient and Population Health, In: S.M. Denisco, A.M. Barker (Eds.), Advanced Practice Nursing Essential Knowledge for the Profession, third ed., Jones & Bartlett Learning, Burlington, MA, 2016, pp. 123-147.
OECD/European Observatory on Health Systems and Policies, State of the Health in the EU, Austria: Country Health Profile 2019. https://www.oecd-ilibrary.org/social-issues-migration-health/austria-country-health-profile-2019_fe6121d2-en, 2020.(accessed 4 June 2020).
International Council of Nurses (ICN), NP/APN Network, Definition and Characteristics of the Role. https://international.aanp.org/Practice/APNRoles, 2001-2020.(accessed 29 May 2020).
International Council of Nurses (ICN). GUIDELINES ON ADVANCED PRACTICE NURSING 2020. https://www.icn.ch/system/files/documents/2020-04/ICN_APN%20Report_EN_WEB.pdf, 2020.(accessed 5 June 2020).
Integrative Review of APRN Outcomes and Performance Improvement Research.
in: Tracy M.F. O’Grady E.T. Hamric and Hanson's Advanced Practice Nursing. An integrative Approach. sith ed. Elsevier, St. Louis,
Missouri2014: 585-606
American Association of Colleges of Nursing (AACN), AACN Position Statement on the Practice Doctorate in Nursing. https://www.aacnnursing.org/DNP/Position-Statement, 2004.(accessed 4 June 2020).
American Association of Colleges in Nursing (AACN), APRN Consensus Model. https://www.aacnnursing.org/Education-Resources/APRN-Education/APRN-Consensus-Model, 2008.(accessed 5 June 2020).
Bundeskanzleramt, Bundesgesetz über Gesundheits- und Krankenpflegeberufe (Gesundheits- und Krankenpflegegesetz – GuKG). https://www.ris.bka.gv.at/GeltendeFassung.wxe?Abfrage=Bundesnormen&Gesetzesnummer=10011026, 2020.(accessed 4 June 2020).
Bundesministerium für Soziales, Gesundheit, Pflege und Konsumentenschutz, Gesundheitsberuferegister, Öffentliches Register. https://gbr-public.ehealth.gv.at/2020 (accessed 4 June 2020).
Bundesministerium für Arbeit, Soziales, Gesundheit und Konsumentenschutz, Outcome-Messung im Gesundheitswesen basierend auf dem Mess- und Vergleichskonzept. https://primaerversorgung.org/wp-content/uploads/2020/01/2018_Outcome-Messung-im-Gesundheitswesen.pdf, 2017 (accessed 4 June 2020).
in: Mateo M.A. Foreman M.D. Research for advanced practice nurses From Evidence to Practice. second ed. Springer Publishing Company,
New York2014: 375-394
Role of the Advanced Nurse Practitioner Within Teenage and YOUNG Adult Oncology. What is the Impact on Patient and Staff Experience of a New Nurse Practitioner Role to a Teenage and Young Adult Service?.
J Adolesc Young Adult Oncol.2019; 8 (https://doi.org/10.1089/jayao.2019.0020): 668-673
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