Technical comment

Comment on: Chmiel C, et al. Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care

DOI: https://doi.org/10.4414/smw.2019.20008
Publication Date: 10.03.2019
Swiss Med Wkly. 2019;149:w20008

Koch Roswithaa, Mahrer-Imhof Romyb, Huber Claudiacd, Schmid-Mohler Gabrielae, Fierz Katharinaf, Zúñiga Franziskag, Tuma Jean-Luch, Ullmann-Bremi Andreai, Bally Christinea, Wiesli Ursulaj, Zumstein-Shaha Mayak, Eicher Manuelal

a SBK Geschäftsstelle Schweiz, Switzerland

b Nursing Science & Care Ltd, Switzerland

c Schweizerische Interessengruppe Diabetesfachberatung (SIDB), Bern, Switzerland

d King's College London, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, London, United Kingdom

e Centre of Clinical Nursing Science, University Hospital Zurich, Switzerland

f Zurich University of Applied Sciences, Switzerland

g Nursing Science, University of Basel, Switzerland

h UniQueCAre, délégué par Swiss Nurse Leaders, Association Nationale des directrices et directeurs des soins, Switzerland

i Universitäts-Kinderspital Zürich, Switzerland

j Stiftung Drei Tannen, Leitung Wissensmanagement, Wald, Switzerland

k Department of Health, Division of Applied Research and Development in Nursing, Bern University of Applied Sciences, Bern, Switzerland

l Institut Universitaire de Formation et de Recherche en Soins, Faculté de Biologie et de Médecine, Université de Lausanne, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Recently, Chmiel et al. reported the results of a cross-sectional study that was conducted as a follow-up study after a randomised controlled trial (RCT) testing the effectiveness of a new model of care [1]. This original RCT tested whether the implementation of several elements of the Chronic Care Model via specially trained “Medizinische Praxisassistentinnen” – the authors call them “practice nurses” – increases several clinically relevant patient outcomes for diabetes care (glycaemic control, cardiovascular risk factors), as well as the quality of care [2]. The authors are to be commended for the completion of this trial. Even though the primary endpoint – HbA1c level of diabetes type II patients – was not met, the study advances our understanding of chronic care in general and of diabetes care in particular [3]. As a follow-up, the team of Thomas Rosemann have now published a cross-sectional study to investigate the long-term sustainability of the implementation [1].

Practice nurse and medical assistant in primary care: roles with different clinical responsibilities

The urgent need to clarify the roles and responsibilities of nurses within the context of the Swiss healthcare system, as well as their scopes of practice, has been highlighted recently [4]. Therefore, the use of the term “practice nurse” merits discussion regarding the professional profile of the Swiss “Medizinische Praxisassistentin”. As the authors stated in the protocol of the CARAT study: “In Switzerland, as in most European countries, the education of practice nurses differs tremendously from the US … The education of practice nurses in Switzerland is less focused on medical issues and addresses mainly administrative matters [2]….

We believe that the role of trained “Medizinische Praxisassistentinnen” is very close to the role of trained “medical assistants”, as they are known in the US, who usually work under the licence of a physician. The traditional clinical role of the medical assistant was limited to taking vital signs, accompanying patients to an examination room, noting any patient feedback in the record and then leaving the examination room unless assistance was required with a medical procedure. Although their role has now been transformed in many ways [5], the new, extended scope of practice cannot replace the training and knowledge of a qualified nurse, as stated by Bodenheimer and colleagues: “They cannot make medical assessments, offer medical advice, or triage patients. They may, however, provide information to patients and follow a wide variety of physician-approved protocols provided that training and supervision are in place” [6]. Practice nurses are considered to be primary care clinicians who have acquired at least the competences of a nurse at bachelor level. In many cases, however, they are trained as nurse practitioners at master’s degree level – not only in the US, but also in European countries such as the UK [7].

In addition, Chmiel et al. (2017) state that there is “a lack of appropriately prepared medical staff” to ensure adequate care for chronically ill people, possibly based on the assertion by Frei et al. that “practice nurses represent the only resource for a team approach in primary care” [2]. Chmiel et al. seem not to be aware that, since 1999, nurses have had the option to specialise in diabetes counselling. Nurses who have acquired this specialization already work in family doctors' practices and in the advice centres of the Swiss Diabetes Society in order to deliver care that is targeted and tailored to the needs of patients with diabetes.

Thus, we invite the authors of the CARAT and the follow-up-studies to reconsider their use of the term “practice nurse” in future communications. We believe this role would be better categorized as “medical assistant with an extended scope of practice”. With the current development in nursing roles that includes the development of nurse practitioner roles in the primary care setting, as well as of nurses with a specialisation in diabetes counselling, we should establish well-defined roles in order to enable the population to distinguish clearly between the scopes of practice of the different professionals within the Swiss healthcare system.

Disclosure statement

No financial support and no other potential conflict of interest relevant to this article was reported.

Correspondence

Roswitha Koch, SBK Geschäftsstelle Schweiz, Postfach, Choisystrasse 1, CH-3001 Bern, roswitha.koch[at]sbk-asi.ch

References

1 Chmiel C, Giewer I, Frei A, Rosemann T. Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study. Swiss Med Wkly. 2017;147:w14522. doi:. http://dx.doi.org/10.4414/smw.2017.14522 PubMed

2 Frei A, Chmiel C, Schläpfer H, Birnbaum B, Held U, Steurer J, et al.The Chronic CARe for diAbeTes study (CARAT): a cluster randomized controlled trial. Cardiovasc Diabetol. 2010;9(1):23. doi:. http://dx.doi.org/10.1186/1475-2840-9-23 PubMed

3 Frei A, Senn O, Chmiel C, Reissner J, Held U, Rosemann T. Implementation of the chronic care model in small medical practices improves cardiovascular risk but not glycemic control. Diabetes Care. 2014;37(4):1039–47. doi:. http://dx.doi.org/10.2337/dc13-1429 PubMed

4 Bryant-Lukosius D, Spichiger E, Martin J, Stoll H, Kellerhals SD, Fliedner M, et al.Framework for Evaluating the Impact of Advanced Practice Nursing Roles. J Nurs Scholarsh. 2016;48(2):201–9. doi:. http://dx.doi.org/10.1111/jnu.12199 PubMed

5 Chapman SA, Blash LK. New Roles for Medical Assistants in Innovative Primary Care Practices. Health Serv Res. 2017;52(Suppl 1):383–406. doi:. http://dx.doi.org/10.1111/1475-6773.12602 PubMed

6 Bodenheimer T, Willard-Grace R, Ghorob A. Expanding the roles of medical assistants: who does what in primary care?JAMA Intern Med. 2014;174(7):1025–6. doi:. http://dx.doi.org/10.1001/jamainternmed.2014.1319 PubMed

7 Bradby M, McCallum C, eds. General Practice Nursing in the 21st Century: A Time Of Opportunity. The Queen's Nursing Institute, 2015. https://www.qni.org.uk/wp-content/uploads/2016/09/gpn_c21_report.pdf

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