The content analysis resulted in five main themes: 1) openness despite unfamiliarity with the APN role, 2) differences between GP and APN consultations, 3) competencies and characteristics of the APN, 4) added value and limits of the APN, and 5) safety and quality aspects of APN care. Each theme is described in detail below and exemplified by statements from the patients.
Openness despite unfamiliarity with the APN role
Most patients mentioned that they had no ideas or concepts associated with the term advanced practice nurse or knowledge of the training of an APN. They, therefore, initially saw the APN as an assistant to the GPs, who could take over certain tasks to relieve them.
“The APN has special training, so she can take over a lot of tasks that otherwise the GP would do.” (Practice B)
Although patients felt some uncertainty about the APN role, they were generally willing to consult with one because this was recommended and initiated by their GP. The participants emphasized that they had deep trust in their GPs and therefore relied on them to hire only competent health professionals.
“I simply have complete trust in my GP and thus it seemed right for me.” (Practice B)
Some interviewees mentioned that their openness to the new role was facilitated by the perceived lack of GPs as well as their personal attitude toward a new and innovative healthcare model.
“Yes, the lack of GPs is well known, and I think especially here in our canton; it’s important to experiment and look for other solutions because GPs are not easy to replace.” (Practice A)
Differences between GP and APN consultation
After getting more familiar with the APN role, the patients noted that the work practices and treatments of GPs and APNs were quite similar.
“The APN actually did the same examinations as my GP had done yesterday. And asked the same questions in different words, but with the same content.” (Practice A)
Nevertheless, depending on the nature and complexity of their health problems, patients preferred either the GP or the APN. They considered the medical expertise of a GP to be more comprehensive than that of the APNs. Consequently, all patients attributed more complex and urgent tasks to the area of competence of GPs.
“It’s another level, so [...] if I seriously had something, [...] I would really say that my GP should come by.” (Practice B)
In contrast, APNs were more valued for tasks that are known to be time-consuming. Most of the participants stressed that consultations by the APN often lasted 30 to 60 minutes, whereas GP consultations were usually less than 20 minutes.
“The APN just takes the time. She knows that conversations are important. […] Sometimes it only takes half an hour, sometimes an hour, depending on the situation.” (Practice D)
Patients noticed that all APNs were still supported by the GP, but to varying degrees. One patient compared the situation with medical interns in family practices who needed more support and confirmation at the outset before they develop the skills to carry out tasks on their own.
“It's actually the exact same situation as with medical interns. […] The young doctors who come from training are not able to decide on their own; the doctor has to supervise them.” (Practice A)
Competencies and characteristics of the APN
All patients attributed characteristics like empathetic, pleasant, competent and trustworthy to the APN role.
“The APN is a competent, calm, and representative woman who can listen to patients. And that’s something […] that immediately made me trust this woman.” (Practice B)
Patients emphasized that the APN really cared about their feelings and the impact of the disease on their daily lives. They felt that the APN empowered them in their self-management process by giving advice and applying individualized interventions and strategies.
“The APN gives me tasks and encourages me to solve those tasks somehow. And then I really try to get this under control.” (Practice D)
Another competency that patients attributed to the APN was the initial assessment of needs. They stressed that the knowledge of the APNs enabled them to assess the urgency of the health problem and thus determine whether an appointment with the GP or even hospitalization were indicated.
“If the APN has only been there once or twice, then she knows the patients. And when they are ill, [...] she can decide whether the doctor should come immediately or whether an appointment can be made.” (Practice B)
Many patients reported situations in which the APN referred them to other professional groups, like psychiatrists, or to the notary’s office to draw up a will. Another patient mentioned that, after mutual agreement, the APN had put her in touch with a peer.
“I go to a psychiatrist; my APN recommended him to me because I told her that […] these relaxants were no longer of any use.” (Practice D)
Patients described how the APN also took over medical tasks, such as taking a medical history, checking vital signs, and reviewing lab results as well as performing physical examinations.
“When the APN comes by […], she asks how it’s going and then she says what she needs to do. Let’s say that she has to take blood or that she has to listen to the heart and lungs or those things ...” (Practice B)
Additionally, participants emphasized that the APNs advised them on questions regarding medication intake and made minor changes. A few appreciated that the APNs offered alternatives, such as natural remedies or nutritional advice to minimize medicalization.
“[...] the APN suggested sage drops and explained to me what they were for and when I should take them.” (Practice D)
Added value and limits of the APN
Patients described the APN as a reference person with whom they felt a close relationship and whom they dared to ask questions they would not have asked the GP. They particularly experienced the added value from the holistic care provided by the APN.
“I experience her as a person who has a broad knowledge and who looks at you as a person, how you really are, and also at the environment.” (Practice D)
Nevertheless, patients appreciated being treated by the APN and GP at the same time. In their view, both had different perspectives but still pursued the same treatment goals.
“With the APN, I rather have other problems to solve (pause) I suppose […] often there are private things involved that have an effect. And there you get more personal and closer to the APN than you would ever dare with a GP.” (Practice D)
Multimorbid and elderly patients saw home visits as an enormous relief in terms of organizational and physical effort. In addition, they felt more comfortable at home, making it easier for them to open up and engage with the APN.
“If I have my sessions in the practice, the APN does not experience me as I am at home. You open up differently at home, you also play a different role.” (Practice D)
Regarding the health system, a few patients drew the conclusion that the APN consultations would probably be cheaper than GP consultations and thus lead to lower healthcare costs. Others mentioned concerns about the workload and shortage of GPs and suggested that the APN could be an additional resource to ensure continuity of care.
“I think it is a great experiment and probably also a necessary step to relieve GPs […] by trying to go multi-track with advanced practice nurses.” (Practice A)
On the other hand, some patients from Practices A, B, and C were reluctant to allow the APN to play the leading role in their care and preferred to receive additional confirmation from their GP for the diagnosis and/or treatment of acute minor or chronic diseases.
“The important thing is that you can still talk to the GP when the APN does the examination.” (Practice A)
As a result of such double-checks by the GPs, a few patients reported waiting times during the consultation, which raised questions about the efficiency of the role and the organization within the practice.
“I don't think it’s quite organized yet […]. I think also, for GPs […], they have patients themselves and then there are ‘in-between patients’ […]. I don’t know what it’s like for GPs, if it gets even more stressful for them…” (Practice A)
Safety and quality aspects of APN care
Patients’ safety assurance was often mentioned when talking about the new role and the scope of practice of the APNs. However, the interviewees felt well cared for, partly because of the close collaboration between the GP and the APN, and partly because they realized that the APNs could provide greater continuity of care and were able to assess their own limits and not exceed them. No participant mentioned complications from treatment or moments of uncertainty.
“I think, if I said, ‘Please call the doctor,’ then the APN would do it immediately. I don't get the feeling that she wants to play doctor in the first place.” (Practice B)
All patients emphasized that they were satisfied with the APN consultations. Most reported improvements in psychological well-being, daily activities, or symptoms, such as pain or insomnia, due to the interprofessional care provided by APN and GP.
“With the APN, it’s like when you get a pill and then all of a sudden you feel good.” (Practice D)
“I had a time when I didn’t feel so well because of the pain and sleeping problems. There she was, just insanely good to me, she just helped me.” (Practice D)
Patients felt that the new role added value to the practice, but also emphasized that the APN and GP were equally important and that the aim was not to replace one profession but for them to complement each other.
And then I said to the GP, ‘This APN is so good; you could still recruit a dozen more.’