Experiences of Advanced Practice Nurses in the FAMOUS Research Project
Examples from practice experiences of advanced practice nurses (APNs) in Germany are shown in this article by illustrating various approaches to patient education in primary healthcare.
Advanced Practice Nurses in Germany
The academization of nursing is still in its very first steps in Germany. Bachelor’s degree programs in nursing were first introduced in 2006. Advanced practice nursing has not yet been established in primary health care in Germany and legal requirements for this role still do not exist [1]. Nevertheless, many efforts within nursing practice and research aim to promote the use of APNs. One such effort was the FAMOUS (effects of care of multimorbid patients in general practices by advanced practice nurses) research project [2].
FAMOUS
The purpose of this controlled nonrandomized mixed methods study was to evaluate the care for multimorbid patients by APNs deployed in general practices in rural areas in Germany. Every patient in the FAMOUS project had at least three or more chronic diseases. The objective of FAMOUS was to stabilize the homecare situation of these patients through the involvement of APNs. The intervention took place from October 2021 to March 2024. Each patient in the intervention group (N=859) received evidence-based and person- centred care by an APN for 12 months. The control group (N=1700) received standard care. For evaluation, routine data from health insurance companies for the control group was used [2,3].
Patient Education and Person-centred Care
Patient education played a significant role in the care for multimorbid patients by APNs in the FAMOUS project, with person- centred care being a requirement for successful education. Person- centred care is about engaging with patients’ life contexts based on a mutual valued relationship. Recognizing and respecting individual values, attitudes, and needs builds the basis for the shared decision- making process, a core element of person-centred care. Family members and relevant healthcare providers are also included in the person-centred care process [4]. The following case examples are a selection of the varied educational situations that the APNs encountered. They intend to provide an insight into the complex care and education needs of multimorbid patients in primary health care and show how the APNs managed to meet them.
Complex Education for Complex Needs
The APN visits Ms A. a few weeks after her discharge from hospital, where treatment for her newly diagnosed type 2 diabetes mellitus was initiated. In addition to grade 1 obesity, she has a mild intellectual impairment and urinary incontinence. Ms. A. is 62 years old and lives by herself. She is illiterate. A domestic help, funded through her care insurance relief allowance, supports her with household tasks and shopping. A home care service handles blood glucose monitoring, medication management, and insulin administration. Due to her illiteracy, Ms. A. has never participated in a diabetes education program. She hardly ever leaves the house because of her incontinence. The lack of exercise increases her obesity. As a result of the in-depth medical history assessment, the APN identifies a lack of knowledge in Ms. A. regarding diabetes management and healthy lifestyle. Together they discuss the goals that Ms. A. would like to achieve. Ms. A. wants to feel confident when choosing suitable foods for a healthy diabetes diet. She would also like to go for more walks outside again despite her incontinence. During the next home visit, the APN provides individualized nutrition education using visual materials like a food pyramid to explain food choices and the importance of exercise. The APN repeats key points and uses comprehension questions to assess the gain of knowledge. Discovering that Ms. A. enjoys drawing, the APN encourages her to draw a picture of the food pyramid and to use it on the next shopping trip. The APN involves the domestic help for the practical part of the training. At the supermarket, Ms. A. and the domestic help compare groceries with the hand-drawn food pyramid to choose appropriate items. Later, Ms. A. reports feeling more confident selecting suitable foods. The involvement of the domestic help contributes to a long-lasting effect of this education. On the next visit the APN discusses methods to promote continence with Ms. A. At the patient’s request, the APN instructs her on bladder training to increase the intervals between visits to the toilet. Furthermore, Ms. A. receives a prescription for pelvic floor exercises with the Maria Gerz (2025) Patient Education in Primary Health Care by Advanced Practice Nurses (APN) in Germany physiotherapist and sanitary pads. After a few weeks, the incontinence has improved to such an extent that Ms. A. can go for outdoor walks again. The regular exercise also led to an improvement in her blood sugar levels and body weight.
App-supported Medication Adherence
Mr. M., aged 78, lives by himself and was recently diagnosed with heart failure, requiring regular medication. However, he frequently lacks to follow his medication, leading to several urgent house calls from his physician due to dyspnea and leg edema. To address this, the APN visits Mr. M. and discusses his medication habits. He admits that he often forgets his medications and is unaware about the importance of adherence. The APN explains the nature of heart failure and the necessity of regular medication. Further evaluation reveals that Mr. M.’s lack of daily routines contributes to his forgetfulness. Since he regularly uses a smartphone, the APN suggests a medication reminder app. Together, they set up the free app, which will alert him with audio signals when it is time for his medication. The APN informs his general practitioner, ensuring that any future medication adjustments are reflected in the app. This approach uses technology effectively to address Mr. M.’s adherence challenges.
Acute Intervention Needs
Mrs. L. suffers from dementia, and her husband, Mr. L., uses a wheelchair due to a below-knee amputation. They share a household with their daughter, who is their primary caregiver. During an initial assessment, the APN observes the daughter’s significant emotional strain. Tearfully, she explains, “I can’t even leave the house for two hours to shop in peace.” The family has limited external support. The APN sets care priorities based on the family’s needs. Four days before the next home visit, the daughter is involved in a car accident, resulting in a tibia fracture requiring surgery. She can no longer fully care for her parents. With no supportive network, the family faces a sudden and complex crisis. The APN conducts a comprehensive family mediation to address their current concerns, especially the couple’s fear of being placed in a nursing home. The daughter is mainly worried about ensuring her parents’ personal care, mobility, and nutrition. Based on this assessment, the APN identifies local support services and, through shared decision-making, implements the following measures: a combination of visiting services and day care for the couple, along with home healthcare services. Additionally, neighborhood assistance is activated to expand the support network. Over the following six weeks, the family adjusts well, later reporting that they feel secure with the established support system.
Summary
The APNs applied multiple methods of education according to the individual case situations and used different materials and media to deal with the complex situations. These practical examples illustrate that patient education is a blend of structured and spontaneous approaches. The counseling process is non-linear and requires a high degree of flexibility. Simple situations often show complex intervention needs. This dynamic demands not only professional competence from APNs but also empathy and the ability to collaborate with patients to find solutions. APNs have the potential to play a significant role in primary healthcare. Their skills and expertise are essential for ensuring high-quality patient care and education.
References
- Henderson Colette, Mackavey Carole, Petri Sophie; Wöhrle Olivia (2023) Germany pioneers an expansion of the advanced practice role. International Journal of Advancing Practice 1.
- Stemmer Renate, Büchler Britta, Büttner Matthias, Dera-Ströhm, Christina Klein, et al. (2023) Effects of care of multimorbid patients in general practices by advanced practice nurses (FAMOUS): study protocol for a nonrandomized controlled trial. BMC Health Services Research 23.
- Brehm Lara, Drevermann Ute, Gerz Maria, Kopp Ines, Leyendecker Christine (2024) Patientenedukation in der Primärversorgung. Erfahrungen von Advanced Practice Nurses im Forschungsprojekt FAMOUS. Padua. 19: 215-219.
- McCormack, Brendan (2022). Person-centred care and measurement: The more one sees, the better one knows where to look. Journal of Health Services Research & Policy. 27: 85-87.