Implementation of advanced practice nursing in Brazilian Primary Health Care: methodological path

Miranda Neto, Manoel Vieira de; Almeida, Letícia Yamawaka de; Bonfim, Daiana; Rewa, Talita; Oliveira, Maria Amélia de Campos

doi:10.1590/0034-7167-2021-0614

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Revista Brasileira de Enfermagem

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 75 (05) • 2022 • https://doi.org/10.1590/0034-7167-2021-0614 copy

Implementation of advanced practice nursing in Brazilian Primary Health Care: methodological path

Implementación de prácticas avanzadas de enfermería en la Atención Primaria de Salud brasileña: camino metodológico

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to describe the operationalization of the steps of a model proposed by the Pan American Health Organization for implementing advanced practice nursing in Primary Health Care services.

Methods:

a methodological study, with a qualitative approach, carried out in a local health system located in southern São Paulo. The first six steps of the model were followed: 1) improve health outcomes; 2) identify stakeholders; 3) determine unmet health needs; 4) identify priorities and goals to introduce advanced nursing practices in primary health care; 5) define advanced practice nursing in primary health care; 6) plan implementation strategies.

Results:

in each step, the objectives, methodological strategies and operationalization were described.

Final Considerations:

the model proved to be effective to support the process of development and implementation of advanced practice nursing in the local system studied.

Descriptors:
Advanced Practice Nursing; Nurse Practitioners; Primary Health Care; Nursing Staff; Health Workforce.

Steps		Description
1^st	Improve patient health outcomes by developing human resources in nursing to advance universal health	In this step, one should identify the population with the greatest need for PHC actions, i.e., identify the patients who will be the focus of subsequent steps. PAHO recommends that national actions be directed to the most vulnerable populations with less access to health services.
2^nd	Identify stakeholders	PAHO recommends that countries develop a Pan American collaborative network to start discussions on roles and implementation strategies of APN in national scenarios, exchanging experiences and supporting each other. Nationally, they should identify all stakeholders and related to APN, adopting an interprofessional and expanded perspective, with the participation of professional councils from various health categories, trade unions, universities and policy and strategic decision-makers. The group should be able to clearly understand APN role and their ability to meet the population’s priority health needs.
3^rd	Determine unmet patient health needs	Assessing general health needs, especially unmet needs, to identify the priority focus of APNu actions and so that their practices are directed and intensified towards priority needs.
4^th	Identify priorities and goals to introduce advanced practice nursing roles in primary health care	The data collected in the previous steps should determine and enable the identification of priority health needs, as well as the main barriers and facilitators for implementing APNu. Stakeholders shall establish measurable goals and objectives for the implementation process and subsequent assessment.
5^th	Define advanced practice nursing roles in primary health care	Define the actions to be taken to achieve the goals established in the previous step, outlining strategies, alternatives and solutions to achieve them. PAHO emphasizes that each country should be responsible for defining APNu roles and scope of practice, based on their context and needs, avoiding overlapping with other existing nursing categories. It is recommended that a competency profile be defined, adopted or even developed for APNu’s work to monitor, evaluate and compare performances and impacts in Latin America and the Caribbean.
6^th	Plan implementation strategies	In this step, countries that seek to implement APN should enable and enhance the coalition of leaderships between professional nursing associations, establishing consensus on APNu roles and scope of practice, in addition to clearly explaining how they will enhance and qualify care to health within the scope of PHC. In this way, leaders will be able to defend APN implementation and its role, identifying the necessary resources. For this, it is necessary to create professional regulation strategies, in addition to guidelines and legislation that enable and support APNu practice, being essential the existence of a specialized teaching staff for their professional training.
7^th	Initiate the advanced practice nursing role implementation plan	Identify graduate nursing courses and institutions capable of being the first to develop competency-based curriculum-oriented courses for APN training. At the same time, guidelines, legislation, protocols and professional regulation strategies should be elaborated that act as a guide for APN development and implementation. Countries should guarantee the necessary resources for the training and professional practice of these nurses, seeking to share through evidence the implementation process effectiveness.
8^th	Evaluate APN roles	PAHO reaffirms its role as a supporter of APN implementation assessment, developing research that reveals evidence on this process, so that policymakers have elements to make strategic decisions. At the national level, countries should also develop evaluation research on APN roles and the process of implementing.
9^th	Conduct long-term monitoring of advanced practice nursing roles	This last step consists of a continuous process of evaluation and monitoring of APNu’s actions.

First step: Characterization of epidemiological profile and description of the current model of care in local health systems
Objective	Methodological strategies
1. Trace the local health system population epidemiological profile; 2. Describe the health care model offered.	1. Documentary research and analysis of data from reports available in the databases and official pages of the MHD, SBIBAE and Rede Nossa São Paulo.
Operationalization
Secondary epidemiological data made available by the official information systems of São Paulo in the Health Bulletin in Epidemiology and Information Coordination Data, the MHD and the SBIBAE were collected: a) Indicators of care production and quality available in the monitoring panel of indicators and data of health facilities (managed by the institution) of the last year or the last version available. b) Data from the Atlas of Inequality (2018 (¹⁹19 Rede Nossa São Paulo. Mapa da Desigualdade 2018 [Internet]. São Paulo: Rede Nossa São Paulo; 2018 [cited 2018 Aug 31]. Available from: https://www.nossasaopaulo.org.br/campanhas/#13 https://www.nossasaopaulo.org.br/campanh... ), prepared by Rede Nossa São Paulo, which, since 2012, annually presents a study on the indicators of the 96 city districts.
Second step: Identification of stakeholders and recruitment of participants
Objectives	Strategies
1. Involve stakeholders in the process of developing and implementing advanced nursing practices in LOHSI.	1. Recruitment of professionals from different levels, with the involvement of health professionals, representatives of nursing and medicine class bodies, health administrators and government agencies that participate in the health system management, as well as representatives of users and families.
Operationalization
All stakeholders were identified in the process of developing and implementing APN in LOHSI. For this, invitation was made to participate in the workshops to each stakeholder. This approach was performed individually by phone, messages by application or email. Representatives of the following bodies were invited: Technical Supervision of Health of Campo Limpo and Vila Andrade; South Regional Health Coordination; MHD; MHD Nursing Area; São Paulo Regional Nursing Council directly involved in the Primary Care Practices Workgroup; Management Council for the Technical Supervision of Health in Campo Limpo and Vila Andrade; Brazilian Society of Family and Community Medicine; and SBIBAE Management. Representatives of different professional categories linked to the SBIBAE also participated, namely: primary care and health network manager; primary care technical support coordinator, family and community physician and nurse; health coordinators of FHS services managed by the institution; a representative of senior nurses from the FHS teams; a representative of full nurses from the FHS teams.
Third step: Identification of health needs and a new model of care
Objectives	Strategies
1. Characterize the population’s health needs, gather the phenomenon perception by stakeholders and analyze the strengths and limitations of the current model of care to meet the LOHSI population’s health needs.	1. Conducting a workshop (Workshop I), recorded and filmed, in which the main researcher took on the role of active facilitator, promoting the involvement of participants, valuing the speeches and contributions of all; 2. Analysis of empirical material resulting from the workshop (discourse analysis and use of WebQDA software)(²⁰20 Souza FN, Costa AP, Moreira A. Questionamento no processo de análise de dados qualitativos com apoio do software WebQDA. Eduser. 2016;3(1). https://doi.org/10.34620/eduser.v3i1.28 https://doi.org/10.34620/eduser.v3i1.28... ).
Operationalization
This step involved the assessment of population’s health needs, especially the unmet needs, to identify the priority focus of APNu’s actions, in order to direct their practices to priority needs. The workshop lasted five hours. Data collected in the first step were presented so that participants could reflect on the epidemiological profile and could express what the LOHSI population’s health needs were. Initially, participants were informed about the research object and objectives, and, after reading it, they signed an Informed Consent Form. Then, the workshop’s specific objective was explained, i.e., the problematization of the researched phenomenon, in this case APN development and implementation in PHC. The main researcher presented the results of quantitative data analysis collected in the first step as a trigger for the discussion. It sought to verify participants’ understanding of the theme, related problems, as well as challenges and possibilities to solve them. Moreover, a discussion was held with participants, seeking to answer the following questions, proposed by Smith et al. (2003)(²¹21 Smith A, Latter S, Blenkinsopp A. Safety and quality of nurse independent prescribing: a national study of experiences of education, continuing professional development clinical governance. J Adv Nurs;70(11):2506-17. https://doi.org/10.1111/jan.12392 https://doi.org/10.1111/jan.12392... ): what are the health needs of patients and families? What is the context and what are the consequences of these needs? What constraints contribute to these needs? What are stakeholders’ perceptions about these needs? What additional information is required about these needs? What sources and methods can be used to acquire this information? The product of this first workshop was the involvement of stakeholders, as well as the problematization of phenomena and the identification of challenges and possibilities for APN development and implementation.
Fourth step: Identification of priorities and goals to present advanced practice nurse role
Objectives	Strategies
1. Establish measurable goals and objectives for the implementation process and subsequent evaluation of APN.	1. Workshop (Workshop II) to discuss the data collected in previous steps (identification of priority health needs, main barriers and facilitators for implementing APNu.
Operationalization
The second workshop lasted four hours. Participants, gathered in small groups, discussed the results and identified the priority needs to be supported by APNu. Each group presented its priorities and goals and then a synthesis of all participants was prepared.
Fifth step: Definition of advanced practice nurse roles and the new service model
Objectives	Strategies
1. Compare the current professional profile of nurses in LOHSI PHC with the expected profile of APNu through competences; 2. Identify the perception of nurses, physicians and coordinators on issues related to APN development and implementation; 3. Identify the self-perception of nurses’ competence for frequent care actions in PHC; 4. Identify the perception of BHU coordinators and physicians in relation to the competence of nurses in their service to carry out common care actions in PHC; 5. Identify the association between the generalist nurses’ profile and the self-perception of competences; 6. Identify the necessary changes in LOHSI to change the care model; 7. Define APNu role in this new model; 8. Identify the changes in roles and responsibilities needed to implement new care practices through APN.	1. Elaboration of a questionnaire with closed questions made available on a virtual platform to professionals of the studied LOHSI; 2. Online survey for PHC nurses (full and senior), FHS physician and coordinators; 3. Workshop (Workshop II), with the meeting of small groups for reflection and problematization on the theme; 4. Elaboration of a synthesis of the information worked in the session.
Operationalization
The activities performed can be divided into two great moments: the first, related to the quantitative phase (construction, collection of questionnaire information and analysis) products, and the second, referring to conduction of activities carried out during the qualitative phase through the workshop. a) Quantitative phase: The questionnaire used was prepared by the researcher, based on the instrument by ^{Magnago (2017}22 Magnago C. A formação do enfermeiro e a ampliação do escopo de prática na Atenção Básica no Brasil [Tese]. Rio de Janeiro: Instituto de Medicina Social, Centro Biomédico, Universidade do Estado do Rio de Janeiro; 2017. 218 p.)(²²22 Magnago C. A formação do enfermeiro e a ampliação do escopo de prática na Atenção Básica no Brasil [Tese]. Rio de Janeiro: Instituto de Medicina Social, Centro Biomédico, Universidade do Estado do Rio de Janeiro; 2017. 218 p.), PAHO competences (2018)(⁷7 Organização Pan-Americana de Saúde. Ampliação do papel dos enfermeiros na atenção primária à saúde [Internet]. Washington, D.C.; 2018 [cited 2021 Jul 01]. Available from: http://biblioteca.cofen.gov.br/wp-content/uploads/2018/05/Amplia%C3%A7%C3%A3o-do-papel-dos-enfermeiros-na-aten%C3%A7%C3%A3o-prim%C3%A1ria-%C3%A0-sa%C3%BAde.pdf http://biblioteca.cofen.gov.br/wp-conten... ) and Rewa’s domains of competence (2018) (²³23 Rewa T. Competências para práticas avançadas de enfermagem na atenção primária à saúde no contexto brasileiro [Dissertação]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2018. 99 p.). It dealt with participant characteristics, the service profile in which they work, the opinion on aspects related to regulation, expansion of practice scope and change in professional roles. Four versions of this instrument, proposed to the different respondents (coordinators, senior nurses, full nurses and physicians), were made available on an online platform. Invitations were then sent to stakeholders via e-mail. After expressing agreement to participate in the study, professionals were invited to complete the questionnaire. At the end, 200 subjects fulfilled the participation criteria and were included in this step. b) Qualitative phase: The workshop had the participation of subjects already involved in the previous qualitative steps. As a trigger for the discussion, the presentation of the quantitative phase questionnaire partial results was used, including the respondent profile. Later, in small groups, participants were invited to reflect and problematize the following questions proposed by Bryant-Lukósius and DiCenso (2004)(⁹9 Bryant-Lukosius D, Dicenso A. A framework for the introduction and evaluation of advanced practice nursing roles. J Adv Nurs. 2004;48(5):530-40. https://doi.org/10.1111/j.1365-2648.2004.03235.x https://doi.org/10.1111/j.1365-2648.2004... ): what changes are needed in LOHSI to change the care model? What changes in roles and responsibilities are necessary to implement new care practices derived from APN? What should be APNu role in these practices? Is there a need for additional expertise? If so, would APN role enhance the ability to achieve goals to meet patients’ health care needs? How do we know that? How well does an APN role fit into this new model of care? What are the advantages and disadvantages of an APN role compared to alternative health care provider roles? At the end, the groups presented their provisional syntheses and, later, the final synthesis was prepared, from which the groups suggested roles for APNu’s work.
Sixth step: Planning strategies for the future implementation of advanced practice nursing in local health systems
Objectives	Strategies
1. Identify facilitators and barriers to APN development and implementation; 2. Outline necessary strategies for the process of development and APN implementation in PHC; 3. Identify resources and facilitators for the process of developing and implementing APN in PHC.	1. Workshop (Workshop II) focused on outlining strategies for APN implementation.
Operationalization
This step occurred during the second workshop. Participants addressed the following issues: what are the facilitators and barriers to APN role development and implementation in this LOHSI? What strategies are needed to maximize role facilitators and minimize barriers? What resources and supports are needed for the development and implementation of roles?

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[1] Corresponding author: Manoel Vieira de Miranda Neto E-mail: manoel.miranda@einstein.br