Jessica Gaylord^a, Janette Ribaut^a, Jenny Gentizon^b, Sara Colomer-Lahiguera^b, Laurence Robatto^c, Cédric Mabire^b, Franziska Zúñiga^a, Manuela Eicher^b

^aNursing Science, Department of Public Health, University of Basel, Basel, Switzerland

^bInstitute of Higher Education and Research in Health Care, Faculty of Biology and Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

^cUniversity of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland

Introduction

Advanced Practice Nurses are dedicated to providing and facilitating high-quality, accessible and patient-centred healthcare that effectively addresses the diverse health needs of individuals and communities. They are particularly involved in promoting health, preventing disease and managing complex health conditions. As part of the broader Swiss Nursing Initiative, new regulations are set to take effect governing Advanced Practice Nurse practice at the national level. This has led to a national debate about entry to practice requirements, particularly the educational prerequisites. According to the International Council of Nurses, which provides global leadership in this area, an Advanced Practice Nurse is a registered nurse who has acquired expert knowledge, complex decision-making skills and clinical competencies for expanded practice through additional graduate education, at master’s level or higher.

The specific characteristics of these competencies are shaped by the context in which they practice, including the setting, population served, institutional requirements and regulatory environment. In contrast to other countries, there are no national educational requirements for entry to practice as an Advanced Practice Nurse in Switzerland. This paper explores the debate for master’s level academic preparation as a prerequisite for Advanced Practice Nurse practice as part of the Swiss Nursing Initiative.

Current national discussion

In implementing the Swiss Nursing Initiative, the Federal Office of Public Health is currently contemplating two options for inclusion of the Advanced Practice Nurse into the health professions law (Gesundheitsberufgesetz [GesBG]). Among other issues, the agency has submitted for public comment the question of whether (variant 2) or not (variant 1) solely academic preparation at a master’s in Advanced Practice Nursing level should be required for entry to practice as an Advanced Practice Nurse. The comment period closed on 29 August 2024 and shows that a majority of organisations and stakeholders opted for variant 2 in favour of a Master’s in Advanced Practice Nursing as the entry into practice requirement. Their position is in alignment with the international standards for advanced practice nursing, requiring graduate academic preparation at a master’s level or higher – regardless of clinical focus.

The International Council of Nurses clearly stipulates a full master’s degree programme as a prerequisite for professional recognition of Advanced Practice Nurses, stating that the “educational preparation must be beyond that of a generalist or specialised nurse…”. They add that, “master’s level modules taken as detached courses do not meet this requirement” [1]. Further, requiring this level of academic education will help ensure that Swiss Advanced Practice Nurses are able to deliver the same level of safe, effective, patient-centred care as has been demonstrated in other countries.

In contrast, variant 1 supports an approach that would allow entry to practice as an Advanced Practice Nurse through certain other educational pathways. Proponents argue that this variant better reflects Switzerland’s dual education system. These pathways include continuing education programmes that provide specialised knowledge and relevant credentialing for specific settings, such as the oncology HFP (Höhere Fachprüfung) or emergency nursing NDS HF (Nachdiplom-Studien der höheren Fachschulen) [2].

We fully agree that the dual education system is a strength of the Swiss setting and that the possibility of taking up more expanded roles within this system is important for serving the health needs of the Swiss population. However, these expanded roles must be differentiated from Advanced Practice Nurse roles to avoid a confusion of roles and lower the possible scope of practices and thus missing the gain Advanced Practice Nurses can provide for the Swiss population.

International context for advanced practice nursing roles

The two most common Advanced Practice Nurse roles in Switzerland are Nurse Practitioners and Clinical Nurse Specialists. Nurse Practitioners typically assess, diagnose and treat patients from a comprehensive medical and psychosocial perspective. They can independently manage patients, including ordering diagnostic tests and monitoring findings; initiating, adjusting or discontinuing both pharmacological and non-pharmacological treatments; providing self-management support; and coordinating care. In contrast, Clinical Nurse Specialists focus on patient care at the bedside, providing direct support to nurses and enhancing nursing practice, particularly in complex patient situations. In addition, Clinical Nurse Specialists take on responsibilities at the organisational and system levels to advance evidence-based practice and drive quality and/or process improvement in clinical, teaching and policy roles.

International evidence shows that integrating Advanced Practice Nurses into innovative models of care improves health system efficiency and effectiveness [3]. Moreover, highly educated Advanced Practice Nurses working to their full scope of practice deliver high-quality care, helping to address workforce shortages particularly in primary care [4]. For Switzerland to realise similar gains with Advanced Practice Nurse models of care, we must hold our Advanced Practice Nurses to international standards, including requiring academic preparation at a Master’s level or higher.

What does this mean for Switzerland?

Currently, there are cantonal and regional differences in the regulation of Advanced Practice Nurse roles, leading to differing requirements for entry to practice, particularly for the Nurse Practitioner role. The canton of Vaud was the first in Switzerland to legislate independent Nurse Practitioner practice, incorporating a paragraph on “infirmier.ère.s praticien.ne.s spécialisé.e.s (IPS)” into its cantonal health regulation in 2017. The University of Lausanne has been offering the corresponding master’s-level training since 2018. In 2023, the cantons of Neuchâtel and Valais adopted a legal basis for the Advanced Practice Nurses, and other French-speaking cantons may soon follow. To date, there are no regulations that govern Advanced Practice Nurse professional practice – whether for Nurse Practitioners or Clinical Nurse Specialists – outside of the Romandie. Despite this, master’s programmes for Advanced Practice Nurse entry to practice have been available across Switzerland for over two decades, offered by universities (UNIBAS, UNIL) as well as universities of applied science (BFH, Careum, HES-SO, Ost, SUPSI, ZHAW). In Switzerland, the Clinical Nurse Specialist role, which has a longer history, is more common in hospitals, whereas the newer Nurse Practitioner role is more prominent in primary and long-term care [5].

As outlined by different stakeholders, having a national regulation, as proposed in variant 2, would establish the master’s degree as the appropriate educational requirement for practice as an Advanced Practice Nurse [6, 7]. Further, the majority of organisations that submitted public comments during the consultation process support this position [8]. This would represent an important development in Switzerland, not only as a milestone for the Advanced Practice Nurse role, but also to enhance public understanding of the contributions Advanced Practice Nurses can make. For the role, adoption of variant 2 would lead to consistent, high-level expectations of the skills and competencies that Advanced Practice Nurses can deliver, thereby defining a scope of practice that enables Advanced Practice Nurses to contribute broadly to innovative models of care. By creating a national standard, we are helping to ensure that Advanced Practice Nurses can practice across the country without regional restrictions. Aligning with international standards further contributes to mobility, potentially making it attractive for clinicians from abroad to study and practice in Switzerland. The education pathways allowed by variant 1 are less stringent and would lead to a dilution of the Advanced Practice Nurse profile.

The strongest arguments in favour of master’s prepared-Advanced Practice Nurses are the focus on patient safety and quality of care. As patients and consumers, we deserve services from the highly qualified providers that deliver optimal care in team-based settings. It is important that Advanced Practice Nurse training enables the development of a new, advanced field of practice as a whole and does not merely lead to the acquisition of isolated, extended skills [8]. This is important for patient safety and quality of care, in part through interprofessional parity with our physician colleagues and other healthcare professionals. A Master’s in Science in Nursing is the established international standard, and therefore must serve as a prerequisite for practicing as an Advanced Practice Nurse in Switzerland.

Notes

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflict of interest related to the content of this manuscript was disclosed.

Jessica Gaylord

Pflegewissenschaft - Nursing Science (INS)

Universität Basel, Medizinische Fakultät

Departement Public Health (DPH)

Bernoullistrasse 28

CH-4056 Basel

jessica.gaylord[at]unibas.ch

References

5. Pflegewissenschaft Universität Basel. Universitätsspital Basel, Universitäre Altersmedizin Felix Platter. Modelle der interprofessionellen Versorgung durch Ärzt:innen und Nurse Practitioner im Vergleich mit Modellen mit Physician Assistants/Klinischen Fachspezialist:innen. Basel. 2024.

7. Mahrer-Imhof R, Alterherr J, Eissler C, Petrig M, Piattini S, Ullmann-Bremi A, et al. Minimal Standards for Certificates and Specializations of Advanced Practice Nurses (MiS-APN). APN-CH; 2024.

Establishing educational entry to practice requirements for advanced practice nursing in Switzerland: current debate and nursing perspective