Defining Clinical Assessment Standards for Bachelor s-prepared Nurses in Switzerland

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1 PROFESSION AND SOCIETY Defining Clinical Assessment Standards for Bachelor s-prepared Nurses in Switzerland Lyn S. Lindpaintner, BA, BSN, MD 1, Iren Bischofberger, MNS, MSc, PhD 2, Andrea Brenner, MNS 3, Susanne Knüppel, RN, Med 4, Theresa Scherer, RN, MME 5, Andreas Schmid, MD 6, Monika Schäfer, RN, MNS 7, Hans Rudolf Stoll, MSc 8, Petra Stolz-Baskett, RN, MA 9, Suzanne Weyermann-Etter, MNS 10, & Beatrice Hengartner-Kopp, RN, BSc, MSc 11 1 Lecturer, Institute of Nursing Science, University of Basel, Basel, Switzerland 2 Professor, Head, Master of Science in Nursing by Applied Research Program, Kalaidos University of Applied Sciences, WE G School of Health Sciences, Aarau, Switzerland 3 Head, Clinical Assessment in Bachelor of Science in Nursing Program FHS St.Gallen, University of Applied Science, Nursing Department, St.Gallen, Switzerland 4 Head, Clinical Assessment, SUPSI University of Applied Sciences and Arts of Southern Switzerland Department of Health Professions, Manno, Switzerland 5 Head, Bachelor of Nursing Program, Bern University of Applied Sciences, Division of Health Professions, Bern, Switzerland 6 Lecturer, Bern University of Applied Sciences, Division of Health Professions, Bern, Switzerland 7 Professor, Head, Bachelor of Nursing Program, Kalaidos University of Applied Sciences, WE G School of Health Sciences, Aarau, Switzerland 8 Lecturer, Institute of Nursing Science, University of Basel, Basel, Switzerland 9 Lecturer, Institute of Nursing ZHAW, Zurich University of Applied Sciences, Winterthur, Switzerland 10 Head, Bachelor of Nursing Program, Institute of Health. Fribourg University of Applied Sciences Western Switzerland, Fribourg, Switzerland 11 Lecturer, Bern University of Applied Sciences, Division of Health Professions, Bern, Switzerland Key words Professional standards, international nursing education, clinical assessment Correspondence Dr. Lyn S. Lindpaintner, Institute of Nursing Science, University of Basel, Bernoullistrasse 28, CH 4056 Basel. [email protected] Accepted: April 20, doi: /j x Abstract Purpose: A rigorous process of collaboration among multilingual and multicultural nursing faculties throughout Switzerland to define optimized learning goals for clinical assessment education at the bachelor s level is described in the context of wider European academic harmonization. Formation of a consensus-seeking panel proved a useful strategy for disseminating knowledge among academic nursing faculties in the early years of tertiary nursing education. The process enabled representatives of competing institutions to share scarce resources and articulate the added value of a bachelor s degree in nursing. Conclusions: A consensus-building strategy has applicability for nursing faculties wishing to increase collaboration, efficiency, and effectiveness early in the process of academic nursing development. Lack of availability of learning materials written in the languages of the local clinical setting is a barrier to teaching advanced assessment skills. Clinical Relevance: Clinical assessment education that teaches a systematic approach to data collection, analysis, and reporting is central to producing excellent clinical professionals. In the context of dynamic change in academic nursing settings across Europe, a group of Swiss nursing faculty has undertaken an innovative nationwide collaboration aimed at broadening and harmonizing clinical assessment skills taught at the bachelor s level, with a focus on strengthening the teaching of systematic clinical data collection and data analysis. Rather than presenting research results, this report is a discussion of the rigorous process of collaboration required to achieve this goal. Importantly, this has occurred in a challenging nursing education environment characterized by recent introduction of academic nursing, unfamiliarity with tertiary nursing education among many healthcare stakeholders, a dynamic Europe-wide academic harmonization, 320 Journal of Nursing Scholarship, 2009; 41:3, c 2009 Sigma Theta Tau International

2 Lindpaintner et al. Defining Clinical Assessment multilinguality and multiculturalism, federalism, and budget limitations. As such, this Swiss experience is of potential interest to nursing educators in other settings characterized by some or all of these challenges. An overview of the political context of this effort precedes a portrait of the unique characteristics of Swiss academic nursing, followed by a description of the collaborative effort that was undertaken. Health education reform in Switzerland and political change accompanying the consolidation of the European Union have spurred a transformation in academic nursing education (Schäfer, 2004; Weyermann, 2007). Swiss nursing faculties are newly challenged to articulate the value added by the bachelor s-prepared nurse since the introduction of this credential in The assessment skill set described here was identified by academic Swiss nursing leaders to be underemphasized in traditional Swiss diploma education, and improved bedside assessment skills provided an attractively practical focus to counter criticism of over-academization. In short, many pragmatic drivers motivated Swiss nursing academicians to take this step toward defining an agreed-upon skill set that could be expected to characterize all Swiss nurses with a bachelor s of science in nursing (BSN) degree, as well as the compelling theoretic rationale for standard setting. This rationale was recently well articulated by the American Association of Colleges of Nursing in the 2008 revision of the Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008). Switzerland, located in western Europe but not a member of the European Union, is among the countries signatory to several agreements aimed at creating a European Higher Education Area by 2010 (European Communities, 2009). This so-called Bologna Process, based on the Bologna Declaration of June 19, 1999, is nothing less than an overhaul of Europe s entire university system, replacing a heterogeneous landscape of academic and professional titles with a congruent system of twotiered undergraduate and graduate degree programs (Conference of Rectors of Swiss Universities, 2000). The Bologna Declaration was followed by the Copenhagen Declaration of 2002, which launched a related agreement regarding vocational training (European Commission, 2002). Taken together, the Bologna and Copenhagen processes facilitate mobility and employability of Europe s students and workers (including health professionals) across international borders by creating comparable academic systems, vocational training, and standards. A nursing-specific effort of the Bologna Process has been underway since 2000, as part of Tuning educational structures in Europe or the Tuning Project (Tuning Educational Structures, 2007; Zabalegui et al., 2006). Nursing scientists in 19 countries are taking part in this attempt to define competencies for nurses at the bachelor s level as well as for master s-prepared and doctorally prepared nurses. Forty nursing-specific competencies have been articulated for the bachelor s-prepared nurse (Tuning Educational Structures, 2009b). Analogous to the situation in Europe, there has developed a need to harmonize standards among Swiss BSN programs, not only to enhance the regional mobility of bachelor s level nurses for employment or graduate education, but also as a first step toward ensuring that Swiss BSN students acquire the competencies essential for healthcare providers of the future (World Health Organization, 2005). This article describes a multicultural collaborative effort by representatives of five Swiss BSN programs in German-speaking Switzerland, which importantly also included representatives from the French- and Italian-language BSN programs offered by Universities of Applied Science in the French- and Italianspeaking cantons. From the outset, the delegates from various language regions brought different expectations to the process. Faculty from the Institute of Nursing Science (INS) at the University of Basel in the German-speaking Canton Basel City along with nursing science faculty at four German-language Universities of Applied Science formed a consensus panel to define core competencies for clinical assessment and physical examination skills for BSN graduates; the implementation of these standards, and of specific recommendations for the qualifications of clinical assessment faculty was planned. Delegates from the French- and Italian-language programs were welcomed into the discussions without a binding commitment to the consensus and implementation process. These programs will decide on the definition of competencies to be introduced in their bachelor s curricula at a later date. This agreement to common goals with different regional levels of commitment was a pragmatic prerequisite to successful collaboration, allowing broad participation of all seven Swiss BSN programs in the discussion. This differentiated culturally sensitive collaborative process may serve as a useful model for nursing faculties in other countries as they face the challenge of introducing harmonized curricular content in a context of multilinguality, multiculturality, scarce resources, and rapid change. After an overview of Swiss nursing education, the consensus process and standards will be described, along with a look at challenges for the future. Swiss Nursing Education Swiss nursing has a proud tradition of humanitarian service and affiliation with the International Red Cross 321

3 Defining Clinical Assessment Lindpaintner et al. dating back to The Swiss Red Cross gradually assumed responsibility for nursing education beginning in the 1890s. This unique model for vocational education persisted until harmonization with other health profession education was recommended in 1999 (Mühlherr, 2007). In 2004, the Federal Office for Professional Education and Technology was given the responsibility for regulating nursing education. Under pressure from the Swiss Nurses Association (SBK-ASI), entry-level nursing education was moved to the tertiary level in all regions of the country (Weyermann, 2007), though separated into tertiary A and B levels. Universities and universities of applied science are at the A level, while nursing diploma programs are offered at the B level in colleges of higher vocational education and training (Federal Office for Professional Education and Technology, 2009). The first BSN and master s of science in nursing (MSN) programs at Switzerland s venerable University of Basel were those in nursing science, created in 2000 with the founding of the INS, the first nursing program to be established at a Swiss university. The first Swiss doctorate in nursing science was granted in Basel in Though academic nursing was initially controversial, dynamic developments in nursing education resulted in the creation of six new BSN programs at universities of applied science in German-, French-, and Italian-speaking regions of the country within a short time period, all of the universities of applied science programs accepting their first bachelor s-level students between 2006 and In 2009 the authors expect well over 2,000 students to attend academic programs. There remain significant regional differences in nursing education, for example, in the percentage of nurses expected to complete a bachelor s program. Italian-Speaking Switzerland: The Tessin Italian is the mother tongue of just under 10% of the Swiss population, mainly in Canton Tessin, bordering on Italy, and in southern areas of Canton Graubünden (Presence Switzerland, 2009). Canton Tessin introduced university nursing education in The Scuola Universitaria Professionale della Svizzera Italiana (SUPSI) offers its nursing program within the Dipartimento Sanità (SUPSI, 2009). Since 2008, SUPSI has offered enrollment to 50 students per year in the BSN program. French-Speaking Switzerland: The Suisse Romande or Romandie Bordering on France, the Romandie is made up of seven cantons, four of which are francophone and three of which are bilingual French/German, accounting for just over 20% of the Swiss population (Presence Switzerland, 2009). The Haut Ecole Spécialisée de Suisse occidentale (HES-SO) is a centralized public university of applied science serving this large region (HES-SO, 2009). Within the HES-SO are six instituts de santé, two of which offer bilingual French-German nursing programs and four of which are taught exclusively in French. Beginning in 2002, 100% of nurses in the Romandie have been educated at the HES-SO. These programs converted to BSN programs in 2006 and serve around 1,500 students. In addition, a French-language nursing science institute has recently been established at the University of Lausanne. German-Speaking Switzerland: The Deutschschweiz About 64% of the population of Switzerland lives in 17 German-speaking cantons bordering Germany, Lichtenstein, and Austria. Currently, three public universities of applied science, or Fachhochschule, offer BSN programs: the Berner Fachhochschule Gesundheit (2009), the Zürcher Hochschule für angewandte Wissenschaft in Winterthur (Zürcher Hochschule für angewandte Wissenschaften, 2009), and the Fachhochschule St. Gallen (FHS St. Gallen, 2009). In addition, the privately owned university of applied science WE G Hochschule Gesundheit in Aarau, which between 1997 and 2004 offered access to academic nursing degrees via the University of Maastricht, the Netherlands, has offered an accelerated BSN program since 2006 (WE G Hochschule Gesundheit, 2009). In contrast to the broad adoption of the BSN as entry level nursing education in Romandie, a policy recommendation in 2004 foresaw that graduates of new BSN programs in German-speaking cantons should fill only 5% to 10% of the nursing workforce, with the remainder educated at the diploma level (Swiss Conference of the Cantonal Ministers of Public Health, 2004). Counting the students at the INS in Basel, approximately 350 students are enrolled in German cantonal BSN programs in Switzerland. Swiss Nursing Within the E.U. Context Developments in Switzerland are being watched with interest by colleagues in the above-mentioned European countries because Swiss nursing is viewed as a pioneer in clinical education. Higher nursing education in Europe has traditionally focused on management and teaching as primary areas of academic pursuit. The founders of the INS in Basel departed sharply from this tradition by embracing a more typically Anglo-American curricular approach, explicitly developing an evidence-based, clinically focused curriculum and research portfolio with 322

4 Lindpaintner et al. Defining Clinical Assessment the stated goal of contributing to the interdisciplinary effort to improve patients health outcomes (Institute of Nursing Science, 2003; Kesselring & Von Klitzing, 2006). In this system, the BSN nurse is prepared as a generalist who can give direct patient care at the bedside and requires assessment skills that are more broad and systematic than those previously included in diploma nursing education. This has led to reexamination of curricular approaches to the teaching of clinically related skills in Switzerland, among other innovations. The E.U. Tuning Project explicitly defines the ability to undertake comprehensive and systematic assessment as a core competency for the BSN nurse (Turning Educational Structures, 2009b). However, an accompanying document describes rather circumscribed expectations with respect to history taking and physical assessment: correct examination of the problems, complete execution of viewing and observation, and helping the physical examinations appropriate to the illness (Tuning Educational Structures, 2009a). Indeed, percussion, palpation, and auscultation have been considered the purview of physicians and are not systematically taught in European nursing education (Lindpaintner, 2007). In Switzerland, however, a consensus is building that systematic assessment warrants a more expanded and explicit treatment within a BSN curriculum. Thus, specific competencies related to history taking, physical assessment techniques, synthesizing clinical data through critical reflection, and appropriate clinical decision making formed the skill set at the center of the collaborative effort we describe here. In the context of ongoing discussions in Swiss nursing regarding the most useful nursing diagnosis system, a topic already fully represented in Swiss nursing education, it was decided to focus clinical assessment on data collection, clinical reflection, and communication skills, while leaving decisions about nursing diagnosis terminology to the discretion of the individual institution. Setting Standards for Clinical Assessment The faculties of new BSN programs joined forces with experienced University of Basel faculty to discuss harmonizing standards for these skills at the BSN level. The possibility of pooling resources and sharing curricular materials was attractive in the context of rapidly growing numbers of BSN students and time pressure to create new course offerings. In addition, faculty development in the area of clinical assessment was identified as a high priority because relatively small numbers of available nursing faculty had received clinically oriented graduate education. Conceptual Phase In an effort to ensure that appropriate standards were defined, guidance was sought from international norms (Alexander & Runciman, 2003), from nursing faculty consultants in the United States (A. Belcher, L. Rose, P. Sharp, & S. van Zandt, personal communication, July 6, 2006), and a sample of assessment textbooks written in English were reviewed (Bickley & Hoekelman, 1999; Dillon, 2003; Jarvis, 2004; Wilson & Giddens, 2001). This review provided confirmation that the Basel clinical assessment curriculum was an appropriate starting point for the consensus-building effort. Curriculum development, assistance with curriculum implementation, and faculty development were identified as areas of greatest need. Consensus-Building Process Representatives from participating institutions met in Basel for the first time in August 2006, along with four Swiss nurse practitioners who had completed clinical master s programs in England or the United States and who acted as consultants to the process. In a series of discussions, an Anglo-American approach to health assessment, including systematic history taking, physical assessment, and critical thinking skills, was extensively discussed, and an expansion of Swiss nursing curricula to include these topics systematically was judged by all panel members to be appropriate and desirable at the BSN level. By February 2007 agreements were in place among the German-language institutions by which resources were pooled to support creation of German-language curricular materials reflecting Basel s approach. The participants from French- and Italian-language institutions joined the discussions actively but had no mandate from their home institutions to implement the clinical assessment curriculum. It was clear from the outset that the process of adopting these standards would differ among the language regions. By Swiss law, educational and health systems are organized at the cantonal level, resulting in substantial differences in nursing traditions in the three language areas of Switzerland. Nursing in French-speaking regions of Switzerland traditionally has more similarities to education and practice in France than to those of Germanspeaking Swiss cantons, which in turn shares traditions and characteristics with Germany and Austria. The canton of Tessin is similarly oriented in language, culture, and nursing traditions toward Italy. Thus, not only would panel members ultimately require curricular materials in different languages, but they would be challenged by differing expectations about the best ways to advance the professionalization of nursing. Hence, a simultaneous 323

5 Defining Clinical Assessment Lindpaintner et al. adoption of the standards was never felt to be realistic, and the very notion of seeking nationwide consensus even in a multistep process was initially viewed as extremely improbable. The goal of consensus also did not imply strict standardization. After agreement was reached about learning goals by the German-language universities of applied science, each institution had the freedom to implement the curriculum in a variety of ways. In addition, it was agreed to articulate the consensus standards in joint publications, providing assurance that all participating institutions would have ownership of the recommendations. Representatives from the Italian- and French-language regions remain members of the consensus panel and both are currently exploring the feasibility of adapting the material for their BSN students via internal institutional processes. The experiences in the German-language programs are followed with interest by their colleagues in the Tessin and Romandie. Consensus Standards: Curriculum Assigned credit points. It was agreed that a minimum of 5 European Credit Transfer System (ECTS) points be assigned to the clinical assessment curriculum. Each ECTS point is envisioned as representing 25 to 30 hours of work, including self study hours. As defined by the Bologna Process, the typical bachelor s degree requires 180 ECTS points for graduation. History taking. The distinction was drawn between a complete health history that serves as a database for a complex or extended nursing care relationship, and a brief, problem-focused history designed to efficiently elicit relevant subjective data needed to assess a new complaint. For the latter, a set of 10 cardinal situations were defined (see Table 1). It was agreed that the BSN student can (a) elicit and concisely document a complete health history using appropriate organization and vocabulary; and (b) efficiently elicit an appropriate history for each of the above cardinal symptoms, including general Table 1. Cardinal situations for focused history taking include: Fever Shortness of breath Chest pain Abdominal pain Leg swelling Leg pain Joint pain Back pain Depressivity Dizziness/Collapse Table 2. Essential elements of the physical examination include: General appearance, including fluid status and vital signs Nutritional status including height, weight, and Body Mass Index Mental status Skin Head and neck Musculoskeletal system Thorax and lungs Central cardiovascular system Peripheral vascular system: arterial, venous, and lymphatic Abdomen Central and peripheral nervous system health status, medicines, and relevant risk factors, then state the objective data needed to evaluate the situation further, and finally give a report using professional vocabulary indicating the urgency of the specific case (critical thinking goal). This is learned and evaluated through roleplay situations in which the nurse performs the assessment and then gives a report at the end of a shift to the next nurse who will assume the person s care. This allows evaluation of communication styles appropriate to interviewing versus reporting as well as the data collection and analysis skills. Physical examination. It was agreed that a BSN graduate can perform a screening examination and describe the expected normal findings for the essential elements of the physical examination (see Table 2). Also a BSN graduate can document the findings of the examination in a systematic way using professional terms. Learning goals related to the reproductive system and breast are discussed below and do not include physical examination techniques. Students practice the examination techniques on one another, with supervision. Importantly, the assessments are consistently focused on identifying and responding to the nursing needs of patients, in clear distinction to the goals of medical diagnosis and treatment. The activities of collecting and synthesizing clinical data serve explicitly nursing goals, such as the nursing diagnostic process, the choice of interventions, and the setting of priorities in the clinical environment. These problem-focused exercises support the diagnostic and monitoring function of the nurse (Benner, 1984), aimed at early identification of clinical deterioration or complications. Additional expectations. Urogenital system and female breast. In this unit the emphasis is upon health promotion goals, features of common urogenital syndromes, and principles of communication about stigmatized topics. It is recommended that students view videos showing the techniques and normal findings of these 324

6 Lindpaintner et al. Defining Clinical Assessment examinations. Students do not practice these examinations on one another. Additional expectations: Integration of data and critical thinking. For each unit, discussion of case examples allows an opportunity to integrate subjective and objective data. The importance of the specific clinical context including risk factors for prevalent illnesses is emphasized. In addition, two units focus specifically on integrating the physical examination and assessment of the diabetic patient, in which efficient synthesis of complex data sets is targeted. Consensus Standards: Faculty Credentials For the foreseeable future, an interdisciplinary team made up of a physician educator and a nurse educator will be the standard, at least one of whom is in current clinical practice. A generalist physician with considerable practice experience is preferred. The standard for the nurse educator is a master sprepared nurse, ideally with ongoing clinical responsibilities at an advanced practice level. However, this profile is a rarity in Switzerland today. Therefore, each institution has identified highly motivated faculty-in-training who will receive intensive continuing education in the clinical and didactic skills needed to teach the curricular material. The first faculty training seminar was held in the fall of 2008 and included a participant from the Tessin. Faculty-in-training are encouraged to find clinical work allowing assessment at an advanced practice level, sometimes a difficult challenge. It is recognized that advanced nursing practice needs the broad support of other stakeholders in the healthcare system before the demand for clinical assessment faculty can be fully met. Curriculum Development The organ system approach, though not optimal for introducing nursing frameworks, was chosen for a pragmatic reason: The only comprehensive health assessment textbooks available in the German language, including the one we decided upon (Bickley, Hoekelman, & Naumburg, 2000) a translation of Bates standard textbook (Bickley & Hoekelman, 1999), use this organizational approach. Thirteen additional curricular units were written in German by one of us (L.L.), using a modified organ system approach for history taking and physical examination skills while introducing a nursing framework. For detailed descriptions of physical examination techniques, the student uses the textbook, while the syllabus provides the nursing focus missing in Bates. Using case examples for discussion, self-quizzes, roleplay scenarios, and documentation exercises, the syllabus focuses on assessment skills as they strengthen nursing practice. Practical exercises promote active learning of interviewing and examination skills, and audiovisual support completes the didactic palette. A teacher s manual supplements the student syllabus. A minimum of 1.5 hours of supervised practice of physical examination and history-taking skills will be provided for each unit, with a faculty:student ratio of 1:8. Student evaluations are based on clinical writeups, plus written and practical examinations. Curriculum Implementation All four universities of applied science in Germanspeaking Switzerland successfully introduced a clinical assessment curriculum in Fortunately, three of the panel members meet the high standard for nurse clinician-educator and assumed these responsibilities. One or more enthusiastic physician educators and nursing faculty-in-training have been recruited successfully for each program. There is room for diversity and individuality in the implementation of the consensus standards. Both accelerated BSN programs for experienced nurses and full BSN programs for secondary school graduates are offered. Some institutions teach these groups together, others separately. Some offer clinical assessment as a single new module, others have chosen to integrate the learning goals into existing problem-based learning curricula. Initial feedback from students and faculty is positive. Some students express doubt about the feasibility of integrating physical examination skills into their clinical work. Many students in accelerated BSN programs report that at the end of the course they are more systematic in their assessments and communicate clinical data more professionally. They identify the clinical assessment skill set as one of the most significant elements of bachelor s level preparation. Not surprisingly, BSN students new to nursing need more time to accomplish the learning goals than do experienced nurses. The minimum time requirement of supervised instruction per unit has been extended in some programs. Further curricular units are desired, in particular pediatric assessment. An evaluation based on shared experience is planned. There are early signs that an expanded clinical assessment role for nurses, initially distinctly controversial, is gaining acceptance among Swiss health professionals (Gut, 2007; Vernazza, 2008). Conclusions We describe the first phases of a nationwide effort in Switzerland to define and implement consensus standards for clinical assessment skills at the BSN level, the 325

7 Defining Clinical Assessment Lindpaintner et al. first curricular harmonization of any kind in Swiss nursing. This requires work across linguistically and culturally distinct regions with varied nursing traditions, in much the same way that the larger Bologna process is taking place across Europe. This curriculum is seen to represent a departure from traditional educational approaches and will require further evaluation. It remains unclear whether sufficient numbers of physician or nurse educators can be identified to expand the program nationwide. The curriculum is costly because of the need for curricular and faculty development, and low teaching ratios. Support for further phases of the project is being sought, including translation of a textbook with a nursing focus and further development of teaching materials in appropriate languages. Availability of teaching materials written in the languages used at the bedside promotes adoption of new curricular approaches. Publication of the consensus standards in the SBK-ASI s trilingual nursing journal Krankenpflege is planned. Future discussions with E.U. institutions involved in the Tuning Project may encourage adoption of similar standards in other countries. The vision of growing numbers of bachelor s-prepared nurses equipped with strengthened assessment skills is increasingly embraced within the health system in Switzerland. It is hoped that the result will be a heightened professionalism among Swiss nurses leading to better health outcomes for their patients. At the same time, the experience of the consensus panel may be a useful model for nursing faculties in other countries who wish to share scarce resources and work together to harmonize standards for clinical nursing competencies. Clinical Resources html index.htm VddRok&feature=related References Alexander, M.F., & Runciman, P.J. (2003). ICN framework of competencies for the generalist nurse. Geneva, Switzerland: International Council of Nurses. American Association of Colleges of Nursing. (2008, August 18). The essentials of baccalaureate education for professional nursing practice. Retrieved February 22, 2009, from Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Berner Fachhochschule Gesundheit. (2009). Pflege. Retrieved April 8, 2009, from Bickley, L.S., & Hoekelman, R.A. (1999). Bates guide to physical examination and history taking (7th ed.). Philadelphia, PA: Lippincott. Bickley L.S., Hoekelman, R.A., & Naumburg, E.H. (2000). In L.S. Bickley (Ed.), Bates grosses Untersuchungsbuch [Bates guide to physical examination and history taking] (3rd German ed.; F. Glauner, I. Jahraus, B. Gleissenberger, & S. Bartl, Trans.). Stuttgart, Germany: Georg Thieme Verlag. Conference of Rectors of Swiss Universities. (2000, February 29). The Bologna Declaration: An explanation. Retrieved April 8, 2009, from EEES/Europa/bolognaEUA.doc Dillon, P.D. (2003). Nursing health assessment: A critical thinking, case studies approach. Philadelphia, PA: F. A. Davis. European Commission. (2002, November 29 and 30). The Copenhagen Declaration. Retrieved April 8, 2009, from en.pdf European Communities. (2009). Bologna process. Retrieved April 8, 2009, from policies/educ/bologna/bologna en.html Federal Office for Professional Education and Technology. (2009). Vocational education and training in Switzerland 2007 Facts and figures. Retrieved April 8, 2009, from html?lang=en FHS St. Gallen Bachelors Studies. (2009). Retrieved April 8, 2009, from Gut, C. (2007). Nurse practitioners in der medizinischen Versorgung der Schweiz? Schweizerische Aerztezeitung, 88, Haute Ecole Spécialisée de Suisse occidentale. (2009). Bachelor s degree courses. Retrieved April 8, 2009, from Institute of Nursing Science. (2003). Internal evaluation report Basel, Switzerland: University of Basel. Jarvis, C. (2004). Physical examination & health assessment (4th ed.). St. Louis, MO: W. B. Saunders. Kesselring, A.K., & Von Klitzing, W. (2006). Nursing science courses at the University of Basel/Switzerland. Concept, guidelines, curriculum and evaluation of study results. Gesundheitswesen, 68(12), Lindpaintner, L. (2007). The role of the physical examination in clinical assessment: A useful skill for professional nursing. Pflege, 20(4), Mühlherr, L. (2007). Arbeit-Beruf-Profession-oder: der Weg zur Fachhochschule. Retrieved April 8, 2009, from 326

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