Advanced practice nurses in Swiss primary care – a cross-sectional survey on students' perspectives on primary care as a potential working place

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BEELER, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5073049/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background: The increasing health burden due to an aging and multimorbid population pressures primary care in Switzerland. New care models are needed to support existing structures. Advanced practice nurses with a focus on primary care, nurse practitioners, could be a solution to strengthen the sector. The profession and role of nurse practitioners are fairly new in Switzerland. Additionally, barriers like missing regulations complicate the integration of nurse practitioners into primary care. Aim : To assess current master of nursing students’ attitudes and perspectives on working in primary care. Methods : A cross-sectional survey was conducted. The web-based survey was distributed through the head of studies at every Swiss university or University of Applied Sciences with the program Master of Nursing. Data on the participants' chosen university and majors, future workplace, attitudes toward primary care, and demographic data were gathered from May to November 2023. The quantitative data was analyzed using logistic regression. Results: A total of 178 master of nursing students took part in the study, of whom 63% (112) considered primary care as a potential future workplace. Of those with a nurse practitioner major, 90% are considering working in primary care. The most important factors for their career choice were “career development” and “job satisfaction” which were chosen by 98% of participants. More than half (56%) of master of nursing students cited the current lack of reimbursement as the most negative factor influencing their attitude towards working in primary care, followed by politics (36%). Conclusions : The majority of master's nursing students had a positive attitude towards working in primary care. The participants stated that nurse practitioners will play a major role in primary care in the future. However, there is room for improvement on a national level: more programs with a nurse practitioner major at Swiss universities, a legal framework and billing rate, and a standardized role definition in primary care. Clinical trial number: not applicable. Advanced Practice Nurses Nurse Practitioner Primary Care Nursing Students Nursing Education Career Choices Outpatient Care Figures Figure 1 Figure 2 Background The shortage of primary care doctors and the increasing burden of an aging and multimorbid population challenge the Swiss healthcare system (1). In Switzerland, 2.2 million people are suffering from chronic illnesses or multimorbidity, which makes up one-quarter of the population (2). This affects not only mortality; four out of five deaths in Switzerland are attributed to non-communicable disease (NCDs), but also increases the care effort (3). Older people are more frequently affected by diseases and impairments that affect their ability to cope with everyday life and therefore require more nursing care (4). The Swiss Health Observatory (OBSAN) report from 2021 revealed that 65–80% of the Swiss population (depending on language regions) choose general practitioners (GPs) as their preferred first contact when health issues occur. Maintaining easy and fast access to outpatient healthcare could be a future need for the population. Therefore, new care models are developed to support existing structures with different first points of contact, like mobile apps, pharmacies, and other healthcare professions (5). To cover the increasing future healthcare needs of the population, these new care models must be developed further. One solution could be the introduction of Advanced Practice Nurses (APNs) into primary care. APNs are nurses who hold at least a master’s degree in nursing and have an extended scope of practice to expand healthcare services provided by nurses (6). APNs have existed globally since the 1960s and are considered a needed reform for more efficient and sustainable healthcare models (7). The International Council of Nurses identifies the Clinical Nurse Specialist (CNS) and Nurse Practitioner (NP) as the two most recognized roles internationally (6), operating in North America and Europe (8) (9) (11). CNSs are equipped with advanced nursing knowledge and skills beyond nursing competencies, can make complex decisions in a clinical specialty, and can apply a systems approach to improving care in healthcare organizations. NPs are generalist nurses, who can work, depending on country-specific regulations, as autonomous clinicians. The scope of practice includes diagnosing and treating conditions based on evidence-informed guidelines with a holistic approach (6). NPs mainly work as a part of a multidisciplinary team, either in primary care or as a bridge between specialized and outpatient care (10). In 2000, the first study program for a master of nursing to become an APN was introduced in Switzerland. Today, two universities and five universities of applied sciences offer the master’s program in all three language regions of Switzerland. The duration of the program (between 3 and 6 semesters full-time), possible majors (in APN roles), and the number of credit points (90 ECTS, 120 ECTS, 180 ECTS) vary between the different universities and universities of applied sciences (both hereinafter referred to as universities). APNs have been integrated step by step into the inpatient care sector (11) (12). Starting in 2018, three out of seven universities added the major to become NP according to international standards (13). For this reason, the integration, and development of the CNS role is way more advanced compared to the NP role in the Swiss health system. With the introduction of a new APN role into the Swiss healthcare system, barriers regarding legal regulation and role recognition occurred. Making it questionable how attractive a job in primary care is for master of nursing students who are looking for a specialized APN role in their studies and their future career opportunities. Obstacles at various levels can influence both their attitude toward working in primary care and the attractiveness of that setting. Given those challenges for NPs in Switzerland, this study investigates whether master of nursing students consider working in primary care, and it explores the attitudes, expectations, and perspectives of master of nursing students about working in primary care, including barriers and facilitators with an impact on these dimensions. Methods Study design A cross-sectional study was conducted in a nationwide multicenter setting (a quantitative study with an embedded qualitative study part). The study report follows the checklist for survey studies (CROSS) (14). Data collection methods The questionnaire is based on the validated questionnaire from a study among UK medical students’ attitudes toward their future careers and general practice by Barber et al. (15). For our study, the questionnaire was adapted to the target group of master of nursing students and pilot-tested to further improve the questionnaire’s comprehensiveness. The pilot testing was conducted with 25 master of nursing students. The validated questionnaire was adjusted for answer options in context and wording to the target group. The final web-based survey contained 15 items in three categories: 1) study topic, major, and university; 2) future workplace, important factors for their career choice, and attitudes towards working in primary care; and 3) demographic data. The survey included multiple-choice questions where participants selected the best possible answer from a set of answer choices, Likert items, and free-text answers (see Supplementary I for the full questionnaire). Based on question six, “Please indicate which workplace or work environment you are currently considering,” the participants could choose one or more of the following workplaces: general practice, practice with specialization, Spitex (home care), university/research, hospital, psychiatric clinic, nursing and retirement home, and others. We defined “primary care” as working in general practice, practice with specialization, and home care. Sample characteristics The target study population were master of nursing students in Switzerland. To participate in the study, the participants had to meet the following inclusion criteria: current enrollment at a Swiss university in the study program “Master of Science in Nursing or Nursing Science” in the year 2023. Survey administration For each Swiss university with the study program master of nursing, the responsible head of the study program was approached by phone and email. The planned study was presented in individual meetings to the heads of the study programs. Subsequently, five out of seven universities sent the invitation for the web-based questionnaire directly to the students via email. The other two universities agreed on distributing the study invitations at the university buildings via posters and flyers with QR codes. The study was carried out between May and November 2023. A reminder was sent out to every university. By the end of November, students from all seven universities had participated in the study. Ethical considerations The study does not fall within the scope of the Human Research Act and therefore does not require the approval of the Ethikkommission Nordwest- und Zentralschweiz (Req-2024-01121). The heads of the study programs as well as the master of nursing students were informed about the study’s objectives in emails and flyers. Participation was voluntary and without financial remuneration. All responses were handled confidentially. The study used completely anonymous data, conformed to local law, ethical review, and research policies. Statistical analysis The survey was conducted with the program Qualtrics LLC (Qualtrics, Provo, UT, USA). Statistical analyses, including data preparation and the creation of charts and tables, were performed with R, version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). For descriptive statistics, counts, and percentages are presented, and medians and first and third quartiles (IQR) were calculated. The participants entered their age in a numeric format into the questionnaire. In the analysis, we categorized the data into tertiles. We conducted three multivariable logistic regression models, reporting odds ratios (ORs) and 95% confidence intervals (95% CIs). The first regression model, evaluates the association between different variables (age groups, gender, major, attitude towards primary care (PC), semester, university) and considering primary care as a future workplace. Missing values for the variable age were filled in with multiple imputation.To achieve a good fit, groups were formed for some variables. For the variable universities, three groups were formed out of the seven universities based on the number of participating students (see Supplementary IV). Group one is the Bern University of Applied Sciences (BUAS); group two is the Zurich University of Applied Sciences (ZHAW). The third group is formed by the remaining five universities: the University of Basel, Kalaidos University of Applied Sciences, the University of Lausanne, the Eastern Swiss University of Applied Sciences, and the University of Applied Sciences and Arts of Southern Switzerland (SUPSI). The second and third regression models are used to assess potential associations between considering primary care as a future workplace and important or influencing factors (see Supplementary V & VI). In the questionnaire, the participants could select from a 5-point Likert item (one answer only) which of the pre-listed factors was (i) most important for their career choice and (ii) which factor mostly influenced their attitude towards working in primary care (see Supplementary I). The analyzed dataset (except free text responses) is available as online supplementary material, and all models are published online alongside this article as supplementary tables. The qualitative answers to question nine, “Please briefly explain your attitude toward the option of working personally in primary care,” were analyzed and coded independently by two researchers. The two coding lists were compared, and major themes answering the question were summarized according to their frequencies, providing the basis for the final coding list (16) (see Supplementary VII). Results Respondent characteristics Out of roughly 470 eligible students (17), 200 students from all seven universities with a master's program in nursing in Switzerland took part in the survey, and 178 finished the questionnaire, corresponding to a response rate of 38%. The respondents had a median age of 31 years (IQR 28–35), and most were female (87.6%). The largest part of participants studied at the BUAS (39.9%), followed by the ZHAW (27.5%). The study included students from twenty Swiss cantons and some who live abroad. Table 1 shows the characteristics of the respondents, stratified by their consideration of working in primary care. A comprehensive overview of the characteristics can be found in the supplementary material (see Supplementary II). Table 1: Characteristics of surveyed students, stratified by considering primary care as a workplace Future Workplace: Considering Primary Care No Yes p-value Overall N 66 112 178 Sex (%) 0.352 Female 56 (84.8) 100 (89.3) 156 (87.6) Male 9 (13.6) 12 (10.7) 21 (11.8) Sex not specified 1 (1.5) 0 (0.0) 1 (0.6) Age (median [IQR]) 31 [28, 36] 30 [27, 35] 0.212 31 [28, 35] Age missing (%) 5 (7.6) 4 (3.6) 0.41 9 (5.1) Universities (%) 0.001 Bern University of Applied Sciences (BUAS) 20 (30.3) 51 (45.5) 71 (39.9) Zurich University of Applied Sciences (ZHAW) 15 (22.7) 34 (30.4) 49 (27.5) University of Applied Sciences and Arts of Southern Switzerland (SUPSI) 11 (16.7) 4 (3.6) 15 (8.4) University of Lausanne 11 (16.7) 3 (2.7) 14 (7.9) Kalaidos University of Applied Sciences 4 (6.1) 9 (8.0) 13 (7.3) Eastern Swiss University of Applied Sciences 2 (3.0) 6 (5.4) 8 (4.5) University of Basel 3 (4.5) 5 (4.5) 8 (4.5) Chosen major 1 (%) <0.001 Advanced practice nurse 16 (24.2) 9 (8.0) 25 (14.0) Clinical nurse specialist 23 (34.8) 24 (21.4) 47 (26.4) Nurse Practitioner/Primary Care 4 (6.1) 40 (35.7) 44 (24.7) Research 7 (10.6) 7 (6.2) 14 (7.9) No Major 11 (16.7) 22 (19.6) 33 (18.5) Other 5 (7.6) 10 (8.9) 15 (8.4) Attitude toward working in primary care (%) <0.001 Negative 10 (16.1) 1 (0.9) 11 (6.5) Neutral 16 (25.8) 2 (1.9) 18 (10.7) Positive 36 (58.1) 104 (97.2) 140 (82.8) 1 The Majors in the master of nursing vary at different universities. Most universities offer “Advanced Practice Nursing” and “Research” as majors to distinguish between nurses working in a clinical context who become APN and nurses who work in a nursing research setting. In three universities, it is possible to specialize in the specific APN roles in clinical settings, which are “CNS,” “NP,” and “Primary Care”. Students can mainly choose their major in the third semester, and therefore participants may have no major yet. Quantitative results Two-thirds (63%) of the students considered primary care as a future workplace. The proportion of students considering primary care as a working place did not differ across age groups or sexes, but according to the attitudes towards working personally in primary care and the chosen major (Table 1 and Supplementary II). Among the students who chose the major “NP” or “primary care”, this proportion was 90% compared to 36–66% of students in other major tracks. A total of 83% voted “positive” to whether they wanted to work in PC personally. Almost all students (97.2%) agreed to the statement that APNs will play a major role in primary care in the future. Figure 1 presents the participants who consider primary care as a future working place and provides estimates regarding which factor was important or not for their future career choice. Overall, most factors were considered important by the students, with the top three being “Career development,” “Job satisfaction,” and “Work-life balance”. The table for all participants is available in Supplementary III. Figure 2 shows the likert item responses to influencing factors for students who consider primary care as a future workplace. The most positive influencing factor (81%) for the students is “Other APNs”. This is followed by tutors at the university and by family doctors. The most negative influencing factor is the “current billing situation,” followed by “politics”. The overall table for all participants is available in Supplementary III. Regression analyses results The first regression analysis showed statistically significant associations between the chosen major and a positive attitude toward considering primary care as their future working place (Supplementary IV). In the second regression model, the students' consideration of working in primary care showed statistically significant associations with four predefined factors that they could rank as important in their career choice. (See Supplementary V & VI). Agreements to the item “community-based working (OR 1.95; 95% CI 1.05 to 3.77) and to the item “regulated billing rate” (OR 1.72; 95% CI 1.15 to 2.66) to be important were positively associated with considering to work in primary care, while agreements to the item “duration of education” (OR 0.63; 95% CI 0.41 to 0.94) and to the item “research opportunity” (OR 0.55; 95% CI 0.37 to 0.81) to be important were negatively associated with considering to work in primary care. Moreover, the third regression revealed statistically significant associations between the influencing factor “Media” (OR 2.30; 95% CI 1.25 to 4.48) and considering primary care as a future workplace (see in Supplementary VI). However, 63.5% of respondents chose the neutral answer. Qualitative Results Overall, 159 participants left an explanation in the form of a comment: 129 comments to “positive attitude,” nine comments to “negative attitude,” and 15 comments to “neutral attitude”. The comments were reviewed and sorted into 51 categories by two individual researchers (see Supplementary VII for all answers categorized). The most positive comments were about the approach and chances in primary care (“ absolutely meaningful! Preservation and promotion of quality of life and avoidance of inpatient admissions through early detection” / “Enormous potential for change in our industry!”) For many of the students, the close and direct contact with patients and the concept of autonomous work reflect their positive attitude towards working in primary care (“ Many opportunities with direct patient contact and to work independently."/ "[…] providing continuous care for patient." / “High degree of independence, flat structures, long-term patient care.” ) The most commented categories are displayed in Table 3a. The most quoted reasons for participants who commented about their negative or neutral attitude towards working in primary care are displayed in Tab. 3b. The students have formed strong opinions regarding the role and education system, which indicates that they are aware of the current barriers for NPs in primary care (“ for me, outpatient work doesn't have a good image. In outpatient work, I have the impression that you have to justify much more why you are needed. In hospitals, it's common for there to be nursing experts.” / “Too little regulated by law, too little in-depth study”.) Table 3a : Top five answers comments, explaining the participants' positive attitude towards working in primary care. Voted “Positive” Category Amount Strengthening primary care 26 Working autonomously 25 Working with patients 25 Holistic approach 24 Profession with future 19 Table 3b : Top five answers comments, explaining the participants' neutral/negative attitude towards working in primary care. Voted “Neutral / Negative” Category Amount No outpatient experience 6 Future opportunity, but later in career 4 Other focus 3 Other setting preferred 3 No patient contact preferred 2 Discussion To our knowledge, our study is the first survey exploring future career choices with a focus on primary care among master of nursing students. Two-thirds of the study population, through all majors, were considering primary care as a future workplace. Moreover, 90% of the students who choose “NP” or “primary care” as a major see their future workplace in primary care. Overall, the participants responded positively to the option to work in primary care. Similarly, almost all of them believed that APNs would play a major role in primary care in the future (see Supplementary III). Career choices for nursing students A study of Australian nursing students focused on primary care as a career choice (18). In the study, 23% of the participants ranked primary care settings, including general practice, community settings and community-based mental health settings, as their preferred workplaces after registration. The majority of the participants expect to work at hospitals (>80%). The main reason for this seems to be that practice programs are used as entry-level positions, which facilitates newly registered nurses entering the inpatient sector. In contrast, 97% of the Australian nurse students think it is (moderately to extremely) important to learn the role of a registered nurse in primary care (18). This aligns with the attitude from our study, whereas 97% of the participants stated that APNs will play a major role in primary care in the future. However, the comparison to our study population is challenging for the following reasons: In Australia, nursing is an undergraduate study program with a duration of three years. After the program, the student can get registered and start working as a registered nurse or enroll in a master's program of nursing followed by 5000 hours of advanced practice to become a NP (19). As further literature only reflects on the career choices of nursing students in undergraduate programs without a focus on primary care (20), these results are not comparable to our study. Career choices of medical doctor students A comparison of our findings to medical students' future career choices may reveal some “common ground” facilitators and barriers toward working in a primary care setting (21). In the study from Barber et al., 40% of UK medical students considered a career as a GP attractive (15). In our study, 83% of master's nursing students had a positive attitude towards primary care. Master of nursing students who consider community-based work important are positively associated with choosing primary care as a future workplace in our study. This aligns with the results of the survey among medical students; community-based working also well positively associated with the perception of a career in general practice to be attractive (15). This intuitively seems plausible, e.g., due to positive experiences while working in the setting. In contrast to APN students in regard to working in primary care, studies indicate that medical students consider the status of GPs lower than the status of other medical specializations (22). Both agree with the social importance and pleasant work environment in primary care, but only 55% of medical students rated a job in primary care as attractive (23). Working experience The median age of nursing students in our study population is 31 years, which is higher compared to other master's degree programs in Switzerland (24). The results display that 18% of the participants already gained working experience and completed nursing education with a nursing specialization before starting the master of nursing program, which could explain the higher age of students compared to other master’s degree specialists’ curricula. A study with mainly Swiss master students (77%) confirms this hypothesis, as study participants stated their work experience in nursing between nine and 23 years (with a median of 13 years) and work experience in the APN role between two and six years (with a median of four years) (25). The influence of the media on nursing students’ career choices Among people or institutions that could potentially influence the students’ attitudes toward working in primary care, only the media had a significant positive influence on the students. While most respondents had a neutral opinion, this association still suggests that media should be considered when advertising study programs or sharing research. Social media platforms can be used to make the job of advanced nursing more visible and increase the knowledge of the target population. The home care and nursing home Graubünden (CH) started a TikTok channel in 2022, which is reaching over 500,000 people and connecting people interested in open training positions with employers (26). Another important influence comes from the Swiss APNs, who take part in policymaking and develop the role further by founding interest groups (27) and associations (28). This is recognized by the students; the descriptive results reveal that “other APNs” are the number one positive influence, according to 81% of the students. Legal and financial regulation Since NPs are still relatively new to outpatient care in Switzerland, barriers on different levels occur in their work environment. APNs working in primary care in Switzerland are missing enumeration in the current tariff regulation system. They can currently only bill for a small part of their actual scope of practice (29). Additionally, APNs do not have full legal permission for their scope of practice; this applies, for example, to prescribing drug treatments (30). This situation is discouraging for GPs and APNs who want to work in primary care. Awareness of nurses as primary care providers by the (Swiss) public Nevertheless, the profession of NPs is not commonly known among the Swiss population. The OBSAN report from 2021 indicates that APNs are not requested by patients who are not familiar with APNs. The Swiss population was asked in the report about their preferred treatment provider or person. Only between two percent (people with chronic diseases) and four percent (people without chronic diseases) choose APN as their preferred option (5). A survey of female graduates in master of nursing working in Switzerland confirms this, as only 4.8% of the 2022 APN graduates work at GP practices and only 4.2% work in the role of a NP (31). This demonstrates the barrier of the low role recognition of APNs and NPs working in primary care in Switzerland. Development of a new professional role Another barrier is that the role and scope of practice of the NPs are still forming and thus not fully developed in Switzerland (32). The new role is not yet known by most other healthcare professions or by the patient. Moreover, the missing standardized definition of the scope of practice is linked to unclear responsibilities between the professions (25). Both aspects are leading to challenges when integrating NPs into GP practices. Limitations The limitations of this study need to be considered in interpreting our results. First, at the two universities that did not advertise the survey by email, only a small proportion of students from the university took part in the study. However, five universities used the students’ email addresses and personal advertising to promote the study, thereby reaching 100% of all enrolled master students. Second, we cannot completely rule out a response bias, since students who are already interested in the field might be more likely to participate in a questionnaire regarding their personal preferences or career plans. Nevertheless, students from all universities with the master program participated in the study, which is a strength of this study and gives an overall impression of the attitude of Swiss nursing master students towards working in primary care. And finally, the questionnaire is exploratory in nature and therefore does not claim to be generalizable. Still, it is based on a validated questionnaire that examines the preferences of British medical students for working in primary care. Implications This study has important implications for the future healthcare landscape in Switzerland, especially regarding primary care. Role development and role definition The overall positive attitude of the students indicates that future APNs want to work but also to support and empower the sector, as they see NPs as having a major role in the future. This spirit aligns with the findings of the research of Gysin et al. (33). The study reflects the experience of APNs in the NP role in the Swiss primary care setting. The main findings include that the participating APNs see themselves as pioneers in building up a new care model in primary care. International literature shares the spirit and the need to define the role of NPs in creating change (34). Patients and health professionals who work with APNs in primary care experienced the work as effective and beneficial, with higher patient satisfaction and even a slightly better quality of life for the patients (33). A Swiss study by Lauber et al. describes the interprofessional GP model as very promising and as an innovative way to provide high-quality patient care. The experiences of six GPs about working in a multi-professional team together with APNs were conducted through interviews (35). The definition and implementation of the NP program in Switzerland is also a topic in a national stakeholder dialog, which highlights its relevance (10). Legal framework, including billing system The outcome of the study indicates that the students are aware of the barriers that currently interfere with the integration of APNs into primary care. The current billing situation is the most negative influencing factor for 59% of the students who consider primary care as a future workplace. In addition, the regression showed that students who rated “Regulated billing rate” as an important factor for their career choice are more likely to work in primary care. This highlights the importance of standardized billing rates for NPs in outpatient care settings, which are currently lacking in Switzerland. The billing rate is a largely discussed topic in the progress of the role-forming of NPs. Stakeholders and other researchers in the field view the missing legal framework as a major barrier and the next thing to tackle for implementing NPs in the Swiss outpatient setting (10). Implication for undergraduate education As described in a Dutch study, a government subsidy for APN training programs and the expansion of their scope of practice may increase the uptake of respective training programs (36). While the students seem genuinely interested in primary care workplaces, they perceive a lack of education (programs) in this field, which may hamper their willingness to work in the setting. Our research demonstrated that APNs with an NP major are more attracted to working in primary care. This could also apply to medical undergraduate education. The offer of earlier specialization programs in primary care has the potential to positively affect the student's choices in pursuing a career in this field. This approach is also recommended by the National Health Service (NHS) to overcome GP shortages (37). Conclusion The majority of master's nursing students had a positive attitude towards working in primary care. The participants stated that nurse practitioners will play a major role in primary care in the future. However, there is room for improvement on a national level: more programs with a nurse practitioner major at Swiss universities, a legal framework and billing rate, and a standardized role definition in primary care. Abbreviations APN Advanced Practice Nurse BUAS Bern University of Applied Science CI Confidence intervals CNS Clinical nurse specialist CROSS Checklist for Survey Studies GP General practitioner OBSAN Swiss Health Observatory OR Odds ratio NCD Non-communicable disease NHS National Health Service NP Nurse Practitioner PC Primary Care STROBE Reporting of Observational Studies in Epidemiology SUPSI University of Applied Sciences and Arts of Southern Switzerland QR-Code Quick-Responds Code ZHAW Zurich University of Applied Sciences Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the Swiss ethic committee “Ethikkommission Nordwest- und Zentralschweiz” (EKNZ) (10/09/2024, Req-2024-01121). The participant’s consent was obtained by completing the questionnaire. Consent for publication Not applicable Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding University of Lucerne This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions C.M., and S.N.J. made substantial contributions to the conception and design of the manuscript. C.M., P.B., and R.T. carried out the acquisition and analysis of the data. C.M., P.B. and S.N.J. were involved in drafting the manuscript. C.M., P.B., R.T., S.E. and S.N.J. revised the manuscript critically and added important intellectual content. All authors give their final approval of the version to be published. 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Adomeit P, Brenner G, et al. Arbeitspapier unimedsuisse zur Entwicklung eines Berufsprofils «Nurse Practitioner». 2023 May 2; Available from: https://www.unimedsuisse.ch/application/files/3616/8372/1689/20230502_unimedsuisse_ArbeitspapierNP_DE.pdf Schmid-Mohler G, Clarenbach C, Brenner G, Kohler M, Horvath E, Spielmanns M, et al. Advanced nursing practice in COPD exacerbations: the solution for a gap in Switzerland? ERJ Open Res. 2020 Jun 15;6(2):00354–2019. Spichiger E, Zumstein-Shaha M, Schubert M, Herrmann L. Gezielte Entwicklung von Advanced Practice Nurse-Rollen für spezifische Patient(inn)engruppen in einem Schweizer Universitätsspital. Pflege. 2018;31(1):41–50. Arbeitspapier unimedsuisse zur Entwicklung eines Berufsprofils «Nurse Practitioner». Sharma A, Minh Duc NT, Luu Lam Thang T, Nam NH, Ng SJ, Abbas KS, et al. A Consensus-Based Checklist for Reporting of Survey Studies (CROSS). J Gen Intern Med. 2021 Oct;36(10):3179–87. Barber S, Brettell R, Perera-Salazar R, Greenhalgh T, Harrington R. UK medical students’ attitudes towards their future careers and general practice: a cross-sectional survey and qualitative analysis of an Oxford cohort. BMC Med Educ. 2018 Jul 4;18(1):160. Busetto L, Wick W, Gumbinger C. How to use and assess qualitative research methods. Neurol Res Pract. 2020 May 27;2:14. Bildung – Schweizerischer Verein für Pflegewissenschaft [Internet]. [cited 2023 Oct 24]. Available from: https://www.vfp-apsi.ch/pflegewissenschaft/bildung Bloomfield JG, Gordon CJ, Williams AM, Aggar C. Nursing students’ intentions to enter primary health care as a career option: Findings from a national survey. Collegian. 2015 Jun 1;22(2):161–7. Careers as a nurse practitioner - Becoming a nurse or midwife [Internet]. [cited 2024 Jun 18]. Available from: https://www.health.nsw.gov.au:443/nursing/careers/Pages/practitioner.aspx McCann TV, Clark E, Lu S. Bachelor of Nursing students career choices: A three-year longitudinal study. Nurse Educ Today. 2010 Jan;30(1):31–6. Fang Y, Soljak M, Tan SLL, Smith HE. Medical students’ attitudes towards and views of general practice careers in Singapore: a cross-sectional survey and qualitative analysis. BMC Med Educ. 2022 Apr 11;22(1):266. Denning H, Sheehan C. Medical Student’s Attitudes Towards a Career in General Practice. Ir Med J. 2023;116(6). Pols DHJ, Kamps A, Runhaar J, Elshout G, van Halewijn KF, Bindels PJE, et al. Medical students’ perception of general practice: a cross-sectional survey. BMC Med Educ. 2023 Feb 9;23(1):103. Bundesamt für Statistik (BFS), editor. Hochschulstatistik - Ausgabe 2018 [Internet]. 2018. Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiUz7eJibCGAxV31AIHHe7bN1cQFnoECCMQAQ&url=https%3A%2F%2Fwww.bfs.admin.ch%2Fbfsstatic%2Fdam%2Fassets%2F4582969%2Fmaster&usg=AOvVaw37ZaJuwhtfwY8_ZRBwMu9R&opi=89978449 Beckmann S, Schmid-Mohler G, Spichiger E, Eicher M, Nicca D, Ullmann-Bremi A, et al. Mapping advanced practice nurses’ scope of practice, satisfaction, and drivers of role performance. Pflege. 2024 Feb 14; Südostschweiz. Pflegeinteressierte auf Tiktok ansprechen | Davoserzeitung [Internet]. 2022 [cited 2024 Jun 18]. Available from: https://www.suedostschweiz.ch/aus-dem-leben/um-lehrberufe-zu-sichern-pflegeinteressierte-auf-tiktok-ansprechen IGswissANP [Internet]. [cited 2024 Jun 20]. Home. Available from: https://www.swissanp.ch APN-CH. APN [Internet]. 2024 [cited 2024 Feb 9]. Available from: https://apn-ch.ch/apn/ Eidgenössisches Departement des Innern EDI, Bundesamt für Gesundheit BAG, Abteilung Gesundheitsversorgung und Berufe, editors. Pflegeinitiative: Revision Gesundheitsberufegesetz - Verankerung des Masters in Advanced Practice Nursing [Internet]. 2024. Available from: https://www.bag.admin.ch/dam/bag/de/dokumente/berufe-gesundheitswesen/teritaerstufe/pflegeinitiative/Faktenblaetter/faktenblatt-revision-gesbg-msc-apn.pdf.download.pdf/20240508_Faktenblatt-Revision-GesBG_Msc%20APN_DE.pdf Gysin S, Meier R, van Vught A, Merlo C, Gemperli A, Essig S. Differences in patient population and service provision between nurse practitioner and general practitioner consultations in Swiss primary care: a case study. BMC Fam Pract. 2020;21(1):164. Schweizer Berufsverband der Pflegefachfrauen und Pflegefachmänner (SBK), APN-CH: Reglementierende Organisation, Institut für Pflegewissenschaft Universität Basel (INS)., editor. Masterumfrage 2022 - Befragung von in der Schweiz berufstätigen Absolventinnen und Absolventen eines pflegewissenschaftlichen Master of Science in Nursing Studiums. 2022. Schlunegger MC, Aeschlimann S, Palm R, Zumstein-Shaha M. Competencies of nurse practitioners in family practices: A scoping review. J Clin Nurs. 2023 Jun;32(11–12):2521–32. Gysin S, Sottas B, Odermatt M, Essig S. Advanced practice nurses’ and general practitioners’ first experiences with introducing the advanced practice nurse role to Swiss primary care: a qualitative study. BMC Fam Pract. 2019;20(1):163. Rekha SG. The future of nursing: leading change, advancing health. IP J Paediatr Nurs Sci. 2020 Nov 28;3(3):60–3. Lauber E, Kindlimann A, Nicca D, Altermatt-von Arb R, Sgier C, Staudacher S, et al. Integration of an advanced practice nurse into a primary care practice: a qualitative analysis of experiences with changes in general practitioner professional roles in a Swiss multiprofessional primary care practice. Swiss Med Wkly. 2022;152:w30199. Dankers-de Mari EJCM, van Vught AJAH, Visee HC, Laurant MGH, Batenburg R, Jeurissen PPT. The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study. BMC Health Serv Res. 2023 Jun 6;23(1):580. Medical School Council, editor. By choice – not by chance Supporting medical students towards future GP careers [Internet]. 2016. Available from: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwil-fbL47yHAxXPRvEDHbzQFCcQFnoECBcQAQ&url=https%3A%2F%2Fwww.medschools.ac.uk%2Fmedia%2F2881%2Fby-choice-not-by-chance.pdf&usg=AOvVaw0l0CBMrE5FWjMuCQn7LcUg&opi=89978449 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5073049","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":356499105,"identity":"916031f8-61ed-4546-afb8-7d654c541368","order_by":0,"name":"Charlotte MÜLLER","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIie3OsUrDQBzH8T84dPDCrb+jEl/hL4FWUfBVrkuzZCgIkkkDgi66n/gUUsgcCDjlAQJ2yOTkEHDp0MFLCRbk2uLmcF8Iucv/PlyIfL7/GOzT/Oxmp0SDjEjP+tE2oon7cfcWhf3CfyLQ3WI7kS93H61OVzeSDqdoGeH4+XPUNFzaUea+ZPEWGV0xVBbkyjCio/dkzNoSLAonYeiIJvcMLoJ8KBgTM0xG6Aiv/9BF4q81uezIinFrVLWPJP0tZEl3DBC7CerkinQVKVMG87NHxokR02tLYoHaTaSJ59SmoZQPT6/1Mr04xqDM1TI9D6Vxk00Hv/Ziz3mfz+fz7egbQ7RPHfIwPwMAAAAASUVORK5CYII=","orcid":"","institution":"University of Lucerne","correspondingAuthor":true,"prefix":"","firstName":"Charlotte","middleName":"","lastName":"MÜLLER","suffix":""},{"id":356499106,"identity":"93aafe06-e78e-4b8c-8a22-09e7d7306d70","order_by":1,"name":"Rebecca TOMASCHEK","email":"","orcid":"","institution":"University of Lucerne","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"TOMASCHEK","suffix":""},{"id":356499107,"identity":"2871ff3c-a3a2-4ff1-8f70-84d74e7d75b7","order_by":2,"name":"Stefan ESSIG","email":"","orcid":"","institution":"University of Lucerne","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"","lastName":"ESSIG","suffix":""},{"id":356499108,"identity":"70fff793-ff1a-461e-b047-c8e392b1575e","order_by":3,"name":"Patrick E. BEELER","email":"","orcid":"","institution":"University of Lucerne","correspondingAuthor":false,"prefix":"","firstName":"Patrick","middleName":"E.","lastName":"BEELER","suffix":""},{"id":356499109,"identity":"71b3a5b3-fa0e-48e7-82c6-0469ca3bbfb7","order_by":4,"name":"Stefan NEUNER-JEHLE","email":"","orcid":"","institution":"University of Lucerne","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"","lastName":"NEUNER-JEHLE","suffix":""}],"badges":[],"createdAt":"2024-09-11 18:08:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5073049/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5073049/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86783342,"identity":"64b97af4-1745-4269-8b88-21c9db8e3ba5","added_by":"auto","created_at":"2025-07-15 13:52:55","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":164589,"visible":true,"origin":"","legend":"\u003cp\u003eFactors for career choice of students who consider working in primary care, ranked by \u003cem\u003eimportance\u003c/em\u003e (n = 112).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5073049/v1/6b6824a5341801a284a5607b.png"},{"id":86783341,"identity":"f935454c-606e-4b4b-bdb9-3d17757d2e81","added_by":"auto","created_at":"2025-07-15 13:52:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":107610,"visible":true,"origin":"","legend":"\u003cp\u003eFactors or people \u003cem\u003einfluencing\u003c/em\u003e the students’ attitude towards working in primary care (n = 112).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5073049/v1/963019b41047e49326dc5271.png"},{"id":86784785,"identity":"3a20506c-8537-4570-8056-30c8a008286d","added_by":"auto","created_at":"2025-07-15 14:00:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":965071,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5073049/v1/93dc6ce0-e91d-4592-bb70-ee69e9960845.pdf"},{"id":86783344,"identity":"ca071f0a-87d2-4bfe-b16f-4d80b70b6230","added_by":"auto","created_at":"2025-07-15 13:52:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":344366,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFilefinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-5073049/v1/d892defb43166b64872675da.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Advanced practice nurses in Swiss primary care – a cross-sectional survey on students' perspectives on primary care as a potential working place","fulltext":[{"header":"Background","content":"\u003cp\u003eThe shortage of primary care doctors and the increasing burden of an aging and multimorbid population challenge the Swiss healthcare system (1). In Switzerland, 2.2 million people are suffering from chronic illnesses or multimorbidity, which makes up one-quarter of the population (2). This affects not only mortality; four out of five deaths in Switzerland are attributed to non-communicable disease (NCDs), but also increases the care effort (3). Older people are more frequently affected by diseases and impairments that affect their ability to cope with everyday life and therefore require more nursing care (4). The Swiss Health Observatory (OBSAN) report from 2021 revealed that 65\u0026ndash;80% of the Swiss population (depending on language regions) choose general practitioners (GPs) as their preferred first contact when health issues occur. Maintaining easy and fast access to outpatient healthcare could be a future need for the population. Therefore, new care models are developed to support existing structures with different first points of contact, like mobile apps, pharmacies, and other healthcare professions (5). To cover the increasing future healthcare needs of the population, these new care models must be developed further.\u003c/p\u003e\n\u003cp\u003eOne solution could be the introduction of Advanced Practice Nurses (APNs) into primary care. APNs are nurses who hold at least a master\u0026rsquo;s degree in nursing and have an extended scope of practice to expand healthcare services provided by nurses (6). APNs have existed globally since the 1960s and are considered a needed reform for more efficient and sustainable healthcare models (7). The International Council of Nurses identifies the Clinical Nurse Specialist (CNS) and Nurse Practitioner (NP) as the two most recognized roles internationally (6), operating in North America and Europe (8) (9) (11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCNSs are equipped with advanced nursing knowledge and skills beyond nursing competencies, can make complex decisions in a clinical specialty, and can apply a systems approach to improving care in healthcare organizations. NPs are generalist nurses, who can work, depending on country-specific regulations, as autonomous clinicians. The scope of practice includes diagnosing and treating conditions based on evidence-informed guidelines with a holistic approach (6). NPs mainly work as a part of a multidisciplinary team, either in primary care or as a bridge between specialized and outpatient care (10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn 2000, the first study program for a master of nursing to become an APN was introduced in Switzerland. Today, two universities and five universities of applied sciences offer the master\u0026rsquo;s program in all three language regions of Switzerland. The duration of the program (between 3 and 6 semesters full-time), possible majors (in APN roles), and the number of credit points (90 ECTS, 120 ECTS, 180 ECTS) vary between the different universities and universities of applied sciences (both hereinafter referred to as universities).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAPNs have been integrated step by step into the inpatient care sector (11) (12). Starting in 2018, three out of seven universities added the major to become NP according to international standards (13). For this reason, the integration, and development of the CNS role is way more advanced compared to the NP role in the Swiss health system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith the introduction of a new APN role into the Swiss healthcare system, barriers regarding legal regulation and role recognition occurred. Making it questionable how attractive a job in primary care is for master of nursing students who are looking for a specialized APN role in their studies and their future career opportunities. Obstacles at various levels can influence both their attitude toward working in primary care and the attractiveness of that setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGiven those challenges for NPs in Switzerland, this study investigates whether master of nursing students consider working in primary care, and it explores the attitudes, expectations, and perspectives of master of nursing students about working in primary care, including barriers and facilitators with an impact on these dimensions.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted in a nationwide multicenter setting (a quantitative study with an embedded qualitative study part). The study report follows the checklist for survey studies (CROSS) (14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData collection methods\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe questionnaire is based on the validated questionnaire from a study among UK medical students\u0026rsquo; attitudes toward their future careers and general practice by Barber et al. (15). For our study, the questionnaire was adapted to the target group of master of nursing students and pilot-tested to further improve the questionnaire\u0026rsquo;s comprehensiveness. The pilot testing was conducted with 25 master of nursing students. The validated questionnaire was adjusted for answer options in context and wording to the target group.\u003c/p\u003e\n\u003cp\u003eThe final web-based survey contained 15 items in three categories: 1) study topic, major, and university; 2) future workplace, important factors for their career choice, and attitudes towards working in primary care; and 3) demographic data. The survey included multiple-choice questions where participants selected the best possible answer from a set of answer choices, Likert items, and free-text answers (see Supplementary I for the full questionnaire).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on question six, \u0026ldquo;Please indicate which workplace or work environment you are currently considering,\u0026rdquo; the participants could choose one or more of the following workplaces: general practice, practice with specialization, Spitex (home care), university/research, hospital, psychiatric clinic, nursing and retirement home, and others. We defined \u0026ldquo;primary care\u0026rdquo; as working in general practice, practice with specialization, and home care.\u003c/p\u003e\n\u003cp\u003eSample characteristics\u003c/p\u003e\n\u003cp\u003eThe target study population were master of nursing students in Switzerland. To participate in the study, the participants had to meet the following inclusion criteria: current enrollment at a Swiss university in the study program \u0026ldquo;Master of Science in Nursing or Nursing Science\u0026rdquo; in the year 2023.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSurvey administration\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor each Swiss university with the study program master of nursing, the responsible head of the study program was approached by phone and email. The planned study was presented in individual meetings to the heads of the study programs. Subsequently, five out of seven universities sent the invitation for the web-based questionnaire directly to the students via email. The other two universities agreed on distributing the study invitations at the university buildings via posters and flyers with QR codes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study was carried out between May and November 2023. A reminder was sent out to every university.\u0026nbsp;By the end of November, students from all seven universities had participated in the study.\u003c/p\u003e\n\u003cp\u003eEthical considerations\u003c/p\u003e\n\u003cp\u003eThe study does not fall within the scope of the Human Research Act and therefore does not require the approval of the Ethikkommission Nordwest- und Zentralschweiz (Req-2024-01121). The heads of the study programs as well as the master of nursing students were informed about the study\u0026rsquo;s objectives in emails and flyers. Participation was voluntary and without financial remuneration. All responses were handled confidentially. The study used completely anonymous data, conformed to local law, ethical review, and research policies.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe survey was conducted with the program Qualtrics LLC (Qualtrics, Provo, UT, USA). Statistical analyses, including data preparation and the creation of charts and tables, were performed with R, version 4.3.2 (R Foundation for Statistical Computing, Vienna, Austria). For descriptive statistics, counts, and percentages are presented, and medians and first and third quartiles (IQR) were calculated. The participants entered their age in a numeric format into the questionnaire. In the analysis, we categorized the data into tertiles.\u003c/p\u003e\n\u003cp\u003eWe conducted three multivariable logistic regression models, reporting odds ratios (ORs) and 95% confidence intervals (95% CIs). The first regression model, evaluates the association between different variables (age groups, gender, major, attitude towards primary care (PC), semester, university) and considering primary care as a future workplace. Missing values for the variable age were filled in with multiple imputation.To achieve a good fit, groups were formed for some variables. For the variable universities, three groups were formed out of the seven universities based on the number of participating students (see Supplementary IV). Group one is the Bern University of Applied Sciences (BUAS); group two is the Zurich University of Applied Sciences (ZHAW). The third group is formed by the remaining five universities: the University of Basel, Kalaidos University of Applied Sciences, the University of Lausanne, the Eastern Swiss University of Applied Sciences, and the University of Applied Sciences and Arts of Southern Switzerland (SUPSI).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe second and third regression models are used to assess potential associations between considering primary care as a future workplace and \u003cem\u003eimportant\u003c/em\u003e or \u003cem\u003einfluencing\u003c/em\u003e factors (see Supplementary V \u0026amp; VI).\u0026nbsp;In the questionnaire, the participants could select from a 5-point Likert item (one answer only) which of the pre-listed factors was (i) most \u003cem\u003eimportant\u0026nbsp;\u003c/em\u003efor their career choice and (ii) which factor mostly\u003cem\u003e\u0026nbsp;influenced\u003c/em\u003e their attitude towards working in primary care (see\u0026nbsp;Supplementary\u0026nbsp;I).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analyzed dataset (except free text responses) is available as online supplementary material, and all models are published online alongside this article as supplementary tables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe qualitative answers to question nine, \u0026ldquo;Please briefly explain your attitude toward the option of working personally in primary care,\u0026rdquo; were analyzed and coded independently by two researchers. The two coding lists were compared, and major themes answering the question were summarized according to their frequencies, providing the basis for the final coding list (16) (see Supplementary VII).\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eRespondent characteristics\u003c/h2\u003e\n\u003cp\u003eOut of roughly 470 eligible students (17), 200 students from all seven universities with a master\u0026apos;s program in nursing in Switzerland took part in the survey, and 178 finished the questionnaire, corresponding to a response rate of 38%. The respondents had a median age of 31 years (IQR 28\u0026ndash;35), and most were female (87.6%). The largest part of participants studied at the BUAS (39.9%), followed by the ZHAW (27.5%). The study included students from twenty Swiss cantons and some who live abroad. Table 1 shows the characteristics of the respondents, stratified by their consideration of working in primary care. A comprehensive overview of the characteristics can be found in the supplementary material (see Supplementary II).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Characteristics of surveyed students, stratified by considering primary care as a workplace\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFuture Workplace:\u003c/strong\u003e Considering Primary Care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.352\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e56 (84.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e100 (89.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e156 (87.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e9 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e12 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e21 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eSex not specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e1 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (median [IQR])\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e31 [28, 36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e30 [27, 35]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e31 [28, 35]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAge missing (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e9 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUniversities (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eBern University of Applied Sciences (BUAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e20 (30.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e51 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e71 (39.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eZurich University of Applied Sciences (ZHAW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e34 (30.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e49 (27.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eUniversity of Applied Sciences and Arts of Southern Switzerland (SUPSI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e15 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eUniversity of Lausanne\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e3 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eKalaidos University of Applied Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e13 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eEastern Swiss University of Applied Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e6 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eUniversity of Basel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8 (4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChosen major\u003csup\u003e1\u003c/sup\u003e (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eAdvanced practice nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (24.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e25 (14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eClinical nurse specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e23 (34.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e24 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e47 (26.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eNurse Practitioner/Primary Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e4 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e40 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e44 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eResearch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e7 (6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eNo Major\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e22 (19.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e33 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e10 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e15 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 434px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttitude toward working in primary care (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e10 (16.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003eNeutral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e16 (25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e18 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003ePositive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e36 (58.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e104 (97.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e140 (82.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eThe Majors in the master of nursing vary at different universities. Most universities offer \u0026ldquo;Advanced Practice Nursing\u0026rdquo; and \u0026ldquo;Research\u0026rdquo; as majors to distinguish between nurses working in a clinical context who become APN and nurses who work in a nursing research setting. In three universities, it is possible to specialize in the specific APN roles in clinical settings, which are \u0026ldquo;CNS,\u0026rdquo; \u0026ldquo;NP,\u0026rdquo; and \u0026ldquo;Primary Care\u0026rdquo;. Students can mainly choose their major in the third semester, and therefore participants may have no major yet.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eQuantitative results\u003c/h2\u003e\n\u003cp\u003eTwo-thirds (63%) of the students considered primary care as a future workplace. The proportion of students considering primary care as a working place did not differ across age groups or sexes, but according to the attitudes towards working personally in primary care and the chosen major (Table 1 and Supplementary II). Among the students who chose the major \u0026ldquo;NP\u0026rdquo; or \u0026ldquo;primary care\u0026rdquo;, this proportion was 90% compared to 36\u0026ndash;66% of students in other major tracks. A total of 83% voted \u0026ldquo;positive\u0026rdquo; to whether they wanted to work in PC personally.\u003c/p\u003e\n\u003cp\u003eAlmost all students (97.2%) agreed to the statement that APNs will play a major role in primary care in the future.\u003c/p\u003e\n\u003cp\u003eFigure 1 presents the participants who consider primary care as a future working place and provides estimates regarding which factor was \u003cem\u003eimportant\u003c/em\u003e or not for their future career choice. Overall, most factors were considered \u003cem\u003eimportant\u003c/em\u003e by the students, with the top three being \u0026ldquo;Career development,\u0026rdquo; \u0026ldquo;Job satisfaction,\u0026rdquo; and \u0026ldquo;Work-life balance\u0026rdquo;. The table for all participants is available in Supplementary III.\u003c/p\u003e\n\u003cp\u003eFigure 2 shows the likert item responses to \u003cem\u003einfluencing\u003c/em\u003e factors for students who consider primary care as a future workplace. The most positive \u003cem\u003einfluencing factor\u003c/em\u003e (81%) for the students is \u0026ldquo;Other APNs\u0026rdquo;. This is followed by tutors at the university and by family doctors. The most negative \u003cem\u003einfluencing\u003c/em\u003e factor is the \u0026ldquo;current billing situation,\u0026rdquo; followed by \u0026ldquo;politics\u0026rdquo;. The overall table for all participants is available in Supplementary III. \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eRegression analyses results\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe first regression analysis showed statistically significant associations between the chosen major and a positive attitude toward considering primary care as their future working place (Supplementary IV).\u003c/p\u003e\n\u003cp\u003eIn the second regression model, the students\u0026apos; consideration of working in primary care showed statistically significant associations with four predefined factors that they could rank as \u003cem\u003eimportant\u003c/em\u003e in their career choice. (See Supplementary V \u0026amp; VI). Agreements to the item \u0026ldquo;community-based working (OR 1.95; 95% CI 1.05 to 3.77) and to the item \u0026ldquo;regulated billing rate\u0026rdquo; (OR 1.72; 95% CI 1.15 to 2.66) to be \u003cem\u003eimportant\u003c/em\u003e were positively associated with considering to work in primary care, while agreements to the item \u0026ldquo;duration of education\u0026rdquo; (OR 0.63; 95% CI 0.41 to 0.94) and to the item \u0026ldquo;research opportunity\u0026rdquo; (OR 0.55; 95% CI 0.37 to 0.81) to be \u003cem\u003eimportant\u003c/em\u003e were negatively associated with considering to work in primary care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, the third regression revealed statistically significant associations between the \u003cem\u003einfluencing\u003c/em\u003e factor \u0026ldquo;Media\u0026rdquo; (OR 2.30; 95% CI 1.25 to 4.48) and considering primary care as a future workplace (see in Supplementary VI). However, 63.5% of respondents chose the neutral answer.\u003c/p\u003e\n\u003ch2\u003eQualitative Results\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eOverall, 159 participants left an explanation in the form of a comment: 129 comments to \u0026ldquo;positive attitude,\u0026rdquo; nine comments to \u0026ldquo;negative attitude,\u0026rdquo; and 15 comments to \u0026ldquo;neutral attitude\u0026rdquo;. The comments were reviewed and sorted into 51 categories by two individual researchers (see Supplementary VII for all answers categorized). The most positive comments were about the approach and chances in primary care (\u0026ldquo;\u003cem\u003eabsolutely meaningful! Preservation and promotion of quality of life and avoidance of inpatient admissions through early detection\u0026rdquo; / \u0026ldquo;Enormous potential for change in our industry!\u0026rdquo;)\u0026nbsp;\u003c/em\u003eFor many of the students, the close and direct contact with patients and the concept of autonomous work reflect their positive attitude towards working in primary care (\u0026ldquo;\u003cem\u003eMany opportunities with direct patient contact and to work independently.\u0026quot;/ \u0026quot;[\u0026hellip;] providing continuous care for patient.\u0026quot; / \u0026ldquo;High degree of independence, flat structures, long-term patient care.\u0026rdquo; )\u0026nbsp;\u003c/em\u003eThe most commented categories are displayed in Table 3a.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe most quoted reasons for participants who commented about their \u003cem\u003enegative\u003c/em\u003e or \u003cem\u003eneutral attitude\u003c/em\u003e towards working in primary care are displayed in Tab. 3b. The students have formed strong opinions regarding the role and education system, which indicates that they are aware of the current barriers for NPs in primary care (\u0026ldquo;\u003cem\u003efor me, outpatient work doesn\u0026apos;t have a good image. In outpatient work, I have the impression that you have to justify much more why you are needed. In hospitals, it\u0026apos;s common for there to be nursing experts.\u0026rdquo; / \u0026ldquo;Too little regulated by law, too little in-depth study\u0026rdquo;.) \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 3a : Top five answers comments, explaining the participants\u0026apos; positive attitude towards working in primary care.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 242px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVoted \u0026ldquo;Positive\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eStrengthening primary care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eWorking autonomously\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eWorking with patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eHolistic approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eProfession with future\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3b : Top five answers comments, explaining the participants\u0026apos; neutral/negative attitude towards working in primary care.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 287px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVoted \u0026ldquo;Neutral / Negative\u0026rdquo;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eNo outpatient experience\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eFuture opportunity, but later in career \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eOther focus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eOther setting preferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eNo patient contact preferred\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, our study is the first survey exploring future career choices with a focus on primary care among master of nursing students. Two-thirds of the study population, through all majors, were considering primary care as a future workplace. Moreover, 90% of the students who choose \u0026ldquo;NP\u0026rdquo; or \u0026ldquo;primary care\u0026rdquo; as a major see their future workplace in primary care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOverall, the participants responded positively to the option to work in primary care. Similarly, almost all of them believed that APNs would play a major role in primary care in the future (see Supplementary III).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCareer choices for nursing students\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA study of Australian nursing students focused on primary care as a career choice (18). In the study, 23% of the participants ranked primary care settings, including general practice, community settings and community-based mental health settings, as their preferred workplaces after registration. The majority of the participants expect to work at hospitals (\u0026gt;80%). The main reason for this seems to be that practice programs are used as entry-level positions, which facilitates newly registered nurses entering the inpatient sector. In contrast, 97% of the Australian nurse students think it is (moderately to extremely) important to learn the role of a registered nurse in primary care (18). This aligns with the attitude from our study, whereas 97% of the participants stated that APNs will play a major role in primary care in the future. However, the comparison to our study population is challenging for the following reasons: In Australia, nursing is an undergraduate study program with a duration of three years. After the program, the student can get registered and start working as a registered nurse or enroll in a master\u0026apos;s program of nursing followed by 5000 hours of advanced practice to become a NP (19). As further literature only reflects on the career choices of nursing students in \u003cem\u003eundergraduate\u003c/em\u003e programs without a focus on primary care (20), these results are not comparable to our study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCareer choices of medical doctor students\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA comparison of our findings to medical students\u0026apos; future career choices may reveal some \u0026ldquo;common ground\u0026rdquo; facilitators and barriers toward working in a primary care setting (21). In the study from Barber et al., 40% of UK medical students considered a career as a GP attractive (15). In our study, 83% of master\u0026apos;s nursing students had a positive attitude towards primary care. Master of nursing students who consider community-based work important are positively associated with choosing primary care as a future workplace in our study. This aligns with the results of the survey among medical students; community-based working also well positively associated with the perception of a career in general practice to be attractive (15). This intuitively seems plausible, e.g., due to positive experiences while working in the setting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn contrast to APN students in regard to working in primary care, studies indicate that medical students consider the status of GPs lower than the status of other medical specializations (22). Both agree with the social importance and pleasant work environment in primary care, but only 55% of medical students rated a job in primary care as attractive (23).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWorking experience\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe median age of nursing students in our study population is 31 years, which is higher compared to other master\u0026apos;s degree programs in Switzerland (24). The results display that 18% of the participants already gained working experience and completed nursing education with a nursing specialization before starting the master of nursing program, which could explain the higher age of students compared to other master\u0026rsquo;s degree specialists\u0026rsquo; curricula. A study with mainly Swiss master students (77%) confirms this hypothesis, as study participants stated their work experience in nursing between nine and 23 years (with a median of 13 years) and work experience in the APN role between two and six years (with a median of four years) (25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe influence of the media on nursing students\u0026rsquo; career choices\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAmong people or institutions that could potentially influence the students\u0026rsquo; attitudes toward working in primary care, only the media had a significant positive influence on the students. While most respondents had a neutral opinion, this association still suggests that media should be considered when advertising study programs or sharing research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSocial media platforms can be used to make the job of advanced nursing more visible and increase the knowledge of the target population. The home care and nursing home Graub\u0026uuml;nden (CH) started a TikTok channel in 2022, which is reaching over 500,000 people and connecting people interested in open training positions with employers (26). Another important influence comes from the Swiss APNs, who take part in policymaking and develop the role further by founding interest groups (27) and associations (28). This is recognized by the students; the descriptive results reveal that \u0026ldquo;other APNs\u0026rdquo; are the number one positive influence, according to 81% of the students.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegal and financial regulation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSince NPs are still relatively new to outpatient care in Switzerland, barriers on different levels occur in their work environment. APNs working in primary care in Switzerland are missing enumeration in the current tariff regulation system. They can currently only bill for a small part of their actual scope of practice (29). Additionally, APNs do not have full legal permission for their scope of practice; this applies, for example, to prescribing drug treatments (30). This situation is discouraging for GPs and APNs who want to work in primary care.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAwareness of nurses as primary care providers by the (Swiss) public\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNevertheless, the profession of NPs is not commonly known among the Swiss population. The OBSAN report from 2021 indicates that APNs are not requested by patients who are not familiar with APNs. The Swiss population was asked in the report about their preferred treatment provider or person. Only between two percent (people \u003cem\u003ewith\u003c/em\u003e chronic diseases) and four percent (people \u003cem\u003ewithout\u003c/em\u003e chronic diseases) choose APN as their preferred option (5). A survey of female graduates in master of nursing working in Switzerland confirms this, as only 4.8% of the 2022 APN graduates work at GP practices and only 4.2% work in the role of a NP (31). This demonstrates the barrier of the low role recognition of APNs and NPs working in primary care in Switzerland. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDevelopment of a new professional role\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother barrier is that the role and scope of practice of the NPs are still forming and thus not fully developed in Switzerland (32). The new role is not yet known by most other healthcare professions or by the patient. Moreover, the missing standardized definition of the scope of practice is linked to unclear responsibilities between the professions (25). Both aspects are leading to challenges when integrating NPs into GP practices.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThe limitations of this study need to be considered in interpreting our results. First, at the two universities that did not advertise the survey by email, only a small proportion of students from the university took part in the study. However, five universities used the students\u0026rsquo; email addresses and personal advertising to promote the study, thereby reaching 100% of all enrolled master students. Second, we cannot completely rule out a response bias, since students who are already interested in the field might be more likely to participate in a questionnaire regarding their personal preferences or career plans. Nevertheless, students from all universities with the master program participated in the study, which is a strength of this study and gives an overall impression of the attitude of Swiss nursing master students towards working in primary care. And finally, the questionnaire is exploratory in nature and therefore does not claim to be generalizable. Still, it is based on a validated questionnaire that examines the preferences of British medical students for working in primary care.\u003c/p\u003e\n\u003ch2\u003eImplications\u003c/h2\u003e\n\u003cp\u003eThis study has important implications for the future healthcare landscape in Switzerland, especially regarding primary care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRole development and role definition\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe overall positive attitude of the students indicates that future APNs want to work but also to support and empower the sector, as they see NPs as having a major role in the future. This spirit aligns with the findings of the research of Gysin et al. (33). The study reflects the experience of APNs in the NP role in the Swiss primary care setting. The main findings include that the participating APNs see themselves as pioneers in building up a new care model in primary care. International literature shares the spirit and the need to define the role of NPs in creating change (34).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients and health professionals who work with APNs in primary care experienced the work as effective and beneficial, with higher patient satisfaction and even a slightly better quality of life for the patients (33). A Swiss study by Lauber et al. describes the interprofessional GP model as very promising and as an innovative way to provide high-quality patient care. The experiences of six GPs about working in a multi-professional team together with APNs were conducted through interviews (35). The definition and implementation of the NP program in Switzerland is also a topic in a national stakeholder dialog, which highlights its relevance (10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLegal framework, including billing system\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe outcome of the study indicates that the students are aware of the barriers that currently interfere with the integration of APNs into primary care. The current billing situation is the most negative influencing factor for 59% of the students who consider primary care as a future workplace. In addition, the regression showed that students who rated \u0026ldquo;Regulated billing rate\u0026rdquo; as an important factor for their career choice are more likely to work in primary care. This highlights the importance of standardized billing rates for NPs in outpatient care settings, which are currently lacking in Switzerland. The billing rate is a largely discussed topic in the progress of the role-forming of NPs. Stakeholders and other researchers in the field view the missing legal framework as a major barrier and the next thing to tackle for implementing NPs in the Swiss outpatient setting (10).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImplication for undergraduate education\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAs described in a Dutch study, a government subsidy for APN training programs and the expansion of their scope of practice may increase the uptake of respective training programs (36). While the students seem genuinely interested in primary care workplaces, they perceive a lack of education (programs) in this field, which may hamper their willingness to work in the setting. Our research demonstrated that APNs with an NP major are more attracted to working in primary care. This could also apply to medical undergraduate education. The offer of earlier specialization programs in primary care has the potential to positively affect the student\u0026apos;s choices in pursuing a career in this field. This approach is also recommended by the National Health Service (NHS) to overcome GP shortages (37).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe majority of master's nursing students had a positive attitude towards working in primary care. The participants stated that nurse practitioners will play a major role in primary care in the future. However, there is room for improvement on a national level: more programs with a nurse practitioner major at Swiss universities, a legal framework and billing rate, and a standardized role definition in primary care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eAPN\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eAdvanced Practice Nurse\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eBUAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eBern University of Applied Science\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eConfidence intervals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCNS\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eClinical nurse specialist\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eCROSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eChecklist for Survey Studies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eGeneral practitioner\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eOBSAN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eSwiss Health Observatory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eOdds ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eNCD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eNon-communicable disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eNHS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eNational Health Service\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eNP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eNurse Practitioner\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003ePC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003ePrimary Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eSTROBE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eReporting of Observational Studies in Epidemiology\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eSUPSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eUniversity of Applied Sciences and Arts of Southern Switzerland\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eQR-Code\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eQuick-Responds Code\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003eZHAW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 480px;\"\u003e\n \u003cp\u003eZurich University of Applied Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Swiss ethic committee \u0026ldquo;Ethikkommission Nordwest- und Zentralschweiz\u0026rdquo; (EKNZ) (10/09/2024, Req-2024-01121). The participant\u0026rsquo;s consent was obtained by completing the questionnaire.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eUniversity of Lucerne\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eC.M., and S.N.J. made substantial contributions to the conception and design of the manuscript. C.M., P.B., and R.T. carried out the acquisition and analysis of the data. C.M., P.B. and S.N.J. were involved in drafting the manuscript. C.M., P.B., R.T., S.E. and S.N.J. revised the manuscript critically and added important intellectual content.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll authors give their final approval of the version to be published.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eWe wish to thank Thekla Brunkert and Luzia Vetter for their expertise and support. We thank the cooperating universities, and universities of applied science, and the students who participated. Furthermore, we especially want to thank the heads of studies of the Master of Nursing or Nursing Science: Karin Peter from the Kalaidos University of Applied Sciences, Thomas Beer from the Eastern Swiss University of Applied Sciences, Sabina De Geest from the University of Basel, Christian Eissler from the Bern University of Applied Sciences, Andr\u0026eacute; Fringer from the Zurich University of Applied Sciences (ZHAW), Manuela Eicher from the University of Lausanne, and Monica Bianchi from the University of Applied Sciences and Arts of Southern Switzerland (SUPSI).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eJosi R, De Pietro C. Skill mix in Swiss primary care group practices - a nationwide online survey. BMC Fam Pract. 2019 Mar 4;20(1):39. \u003c/li\u003e\n\u003cli\u003eBundesamt f\u0026uuml;r Statistik. Bundesamt f\u0026uuml;r Statistik. 2015 [cited 2024 Feb 13]. 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BMC Fam Pract. 2019;20(1):163. \u003c/li\u003e\n\u003cli\u003eRekha SG. The future of nursing: leading change, advancing health. IP J Paediatr Nurs Sci. 2020 Nov 28;3(3):60\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eLauber E, Kindlimann A, Nicca D, Altermatt-von Arb R, Sgier C, Staudacher S, et al. Integration of an advanced practice nurse into a primary care practice: a qualitative analysis of experiences with changes in general practitioner professional roles in a Swiss multiprofessional primary care practice. Swiss Med Wkly. 2022;152:w30199. \u003c/li\u003e\n\u003cli\u003eDankers-de Mari EJCM, van Vught AJAH, Visee HC, Laurant MGH, Batenburg R, Jeurissen PPT. The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study. BMC Health Serv Res. 2023 Jun 6;23(1):580. \u003c/li\u003e\n\u003cli\u003eMedical School Council, editor. By choice \u0026ndash; not by chance Supporting medical students towards future GP careers [Internet]. 2016. Available from: https://www.google.com/url?sa=t\u0026amp;rct=j\u0026amp;q=\u0026amp;esrc=s\u0026amp;source=web\u0026amp;cd=\u0026amp;ved=2ahUKEwil-fbL47yHAxXPRvEDHbzQFCcQFnoECBcQAQ\u0026amp;url=https%3A%2F%2Fwww.medschools.ac.uk%2Fmedia%2F2881%2Fby-choice-not-by-chance.pdf\u0026amp;usg=AOvVaw0l0CBMrE5FWjMuCQn7LcUg\u0026amp;opi=89978449\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Advanced Practice Nurses, Nurse Practitioner, Primary Care, Nursing Students, Nursing Education, Career Choices, Outpatient Care","lastPublishedDoi":"10.21203/rs.3.rs-5073049/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5073049/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The increasing health burden due to an aging and multimorbid population pressures primary care in Switzerland. New care models are needed to support existing structures. Advanced practice nurses with a focus on primary care, nurse practitioners, could be a solution to strengthen the sector. The profession and role of nurse practitioners are fairly new in Switzerland. Additionally, barriers like missing regulations complicate the integration of nurse practitioners into primary care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e: To assess current master of nursing students’ attitudes and perspectives on working in primary care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional survey was conducted. The web-based survey was distributed through the head of studies at every Swiss university or University of Applied Sciences with the program Master of Nursing. Data on the participants' chosen university and majors, future workplace, attitudes toward primary care, and demographic data were gathered from May to November 2023. The quantitative data was analyzed using logistic regression.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e A total of 178 master of nursing students took part in the study, of whom 63% (112) considered primary care as a potential future workplace. Of those with a nurse practitioner major, 90% are considering working in primary care. The most important factors for their career choice were “career development” and “job satisfaction” which were chosen by 98% of participants. More than half (56%) of master of nursing students cited the current lack of reimbursement as the most negative factor influencing their attitude towards working in primary care, followed by politics (36%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: The majority of master's nursing students had a positive attitude towards working in primary care. The participants stated that nurse practitioners will play a major role in primary care in the future. However, there is room for improvement on a national level: more programs with a nurse practitioner major at Swiss universities, a legal framework and billing rate, and a standardized role definition in primary care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number: \u003c/strong\u003enot applicable.\u003c/p\u003e","manuscriptTitle":"Advanced practice nurses in Swiss primary care – a cross-sectional survey on students' perspectives on primary care as a potential working place","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 13:52:50","doi":"10.21203/rs.3.rs-5073049/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-19T21:18:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-19T12:03:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2024-09-19T12:02:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7d7b88a4-9435-4087-9d0e-1c4612adea1b","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-09T17:08:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 13:52:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5073049","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5073049","identity":"rs-5073049","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}