Providing person-centred healthcare - by new models of advanced nursing practice in cooperation with patients, clinical field and education

The purpose of the project was to develop new working models for advanced practice nurses in the emergency department and in the municipal health care that will contribute to person-centered healthcare services, and to evaluate the new master's program in advanced practice nursing with a focus on the development of advanced clinical competence. The purpose of the project's sub-study 1 was to evaluate whether the master's program in AKS increases students' clinical competence and skills in systematic clinical examination and health assessment of patients with acute, minor illnesses and / or long-term illnesses, and whether the learning outcome meets the need for new AKS roles in healthcare services. Five articles have been published from sub-study 1, i.e. a study on Objective Structured Clinical Examination as a method for clinical examination and one article on self-assessment of clinical competence with the instrument ProffNurse SAS. The third article is an international study where we have used the same measuring instrument, which compares the clinical competence of specialist nursing students and APN students. In the fourth article, a new instrument for measuring person-centered nursing care is tested among students' work colleagues. The results show that the students' clinical competence is developed in line with the learning objectives for the master's program and corresponds to the need for advanced clinical competence for both hospitals and primary health care. Some minor suggestions for improving the master's program emerged. The ProffNurse SAS instrument can be used for follow-up of clinical competence both in education and in the clinic. The ProffNurse SAS instrument was also used in an international study that compared the self-assessed competence of specialist nursing students and AKS students. The student at master's level assesses his clinical competence higher than the student at a lower level. In addition, a study about the assessment of person-centered care was conducted among health professionals in the health services (Person-centered Practice Inventory - Staff scale). The purpose of sub-study 2 was to implement new APN models at one emergency department and in three municipalities within this action research project. Action research as an overall design was used in the entire project and is described in a published study. The longitudinal study in the municipal healthcare showed a clear need for APNs, but that clear roles and responsibilities for APNs must be defined. Barriers between professionals must be discussed. Both doctors and managers were positive about developing APN for the municipal healthcare. At the emergency department, five studies have been conducted, including a study describing the use of the PEPPA reference framework for implementation. One study describes the need for and roles for AKS from the perspective of managers, APNs and nurses. In two studies, the focus was on the difference between nurses', specialist nurses' and APN tasks, responsibilities and roles in emergency departments in Norway and Finland, and on these groups' clinical decision-making in Norway, Finland and Ireland. A study protocol for a pilot study at the emergency department has been published. The focus of this study is patients' trust in APN's competence, care and treatment, measured with the Trust form. The latest study compared the care and treatment of advanced clinical nurses with the standard model of the treating physician. Patients with minor orthopedic injuries were treated by APNs and physicians. A total of 335 patients participated in the study. APNs gave the correct diagnosis in 97.3% of the patient cases and the correct treatment in 93.3% of the cases. The results show that the care and treatment of APNs is of as good quality as the doctors' treatment. In addition, results from a study at an out-of-hours clinic, focused on what kind of tasks and responsibilities would be suitable for an APN, has been published. The project has shown new working models for advanced clinical nurses in the emergency department and in the municipal healthcare that can improve access to person-centered healthcare services. Nurses who study in the new master's program in advanced clinical nursing gain increased clinical competence and evaluate the education as a whole positively.

The content of the master program and the OSCE can be recommended for universities that want to start up similar program. The instrument ProffNurse SAS II showed to be a useful instrument for monitoring the development of clinical competence. The PEPPA framework proved to be a useful framework to identify priority problems and to define new APN models from different stakeholders perspective. The longitudinal study in community healthcare revealed that it is necessary to consider the role and responsibility areas of APNs, professional barriers and economic aspects when implementing new APN models. The outcome study at the emergency clinic showed that APN models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. The expected significance is that this project will have an impact on further development of APN models in Norway and other countries, and a base for further development and research projects.

There is a need for improving the access to healthcare services for patients' with acute illnesses, and/or with long term needs. It is therefore a clear necessity for hospitals and municipalities to improve the staff's competence level, and to ensure that patients receive the correct treatment at the right place, and at the right time. By improving nurses' competence level the access to health care services can be improved. Advanced practice nursing (APN) roles are well established internationally, but the knowledge about APNs roles in Norway is scarce. The APN project will contribute to new models of organizing, managing and delivering high-quality health care services, and thereby contribute to more cost effective services and better patient outcomes. The APN project will contribute to a research based master education in APN with a strong emphasize on students? professional and clinical competence, The aim of study 1 is to evaluate if the master program in APN improves the students' clinical competence, and skills in clinical judgement of patients with acute, minor illnesses and/or long-term needs, and if the learning outcomes meet the needs for the new APN roles in the clinical settings. New APN models at the emergency clinic in Vestre Viken and in three municipalities will be developed, implemented and evaluated longitudinally in close cooperation between representatives from the clinical fields, education and users, and in accordance with action research approach (study 2). Some central effects and outcomes of the new APN models will be evaluated, such as patient satisfaction, increased collaboration in the health care teams, access to services, and decreased hospitals admissions from community health care (study 3). New models of APN will be a new innovation to the Norwegian health care system, challenging traditional ways of working among health care professionals. The strength of the project is the collaboration between the education,practice and users