The Implementation of Advanced Practice Nursing in Primary Health Care: A Comparative Qualitative Study of Enablers and Barriers.

aimTo explore the enablers of and barriers to implementing advanced practice nursing in primary health care in Germany and Brazil.

designA qualitative cross-country comparative study.

methodsNine focus groups were conducted: 4 in Brazil and 5 in Germany with 48 participants (23 primary health care policy stakeholders and 25 nurses practicing in primary health care and general practitioners) between May 2022 and June 2023. The data were analysed by content analysis using a deductive-inductive approach.

resultsOur findings reveal a need for clarity around the concept, specific roles and responsibilities of advanced practice nurses in primary health care. Although there is still no regulation in place for practising advanced practice nursing in either country, clear drivers can be observed, with Germany strengthening community health nursing and Brazil following clinical protocols in nursing practice. Dialogue among stakeholders-at both the policy and practitioner levels-is essential to bridge communication gaps. Additionally, involving patients in the implementation process is crucial for the holistic integration of advanced nursing roles.

conclusionsPolitical, organisational and financial barriers persist, such as the need to establish both legal foundations and regulatory frameworks, enhance political participation within the nursing profession, and involve stakeholders in dialogue and consensus-building efforts. Giving advanced practice nursing a higher priority on political and research agendas-with policy adjustments and input from practitioners-can help integrate advanced practice nursing into primary health care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Our findings highlight that actively involving nursing as an equal partner in political discourse is seen by stakeholders as crucial to drive the implementation process forward sustainably. IMPACT: This study addresses the lack of data on the enablers and barriers to implementing advanced practice nursing in primary health care in Germany and Brazil. It underscores the need for clearer definitions of advanced practice nursing in primary health care, as well as sufficient regulation and funding. Dialogue is essential to bridge gaps and foster mutual understanding. The findings support future practice development and research, especially in countries that have introduced advanced nursing practice roles in primary health care. REPORTING

methodThe COnsolidated criteria for REporting Qualitative research (COREQ). PATIENT OR PUBLIC CONTRIBUTION: No involvement of patient and public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Our study highlights the growing adoption of expanded nursing responsibilities even in countries that have not yet formally implemented advanced practice nursing roles.