Medication and test prescription by nurses: contributions to advanced practice and transformation of care*

ABSTRACT Objective: To carry out a documentary study on the rules, guidelines, policies and institutional support for the nurse to prescribe medicines and request tests with a view to the advanced practice in the scope of Primary Health Care. Methods: Documentary research using open-access institutional documents - Federal Nursing Council (COFEN), its regional representations in the respective Brazilian states (COREN) and the Brazilian Nursing Association (ABEN). Results: Most of the news/notices were issued by the Regional Nursing Councils in the different Federative Units. The argumentation regarding the prescription of medicines and request for tests by nurses is based on three categories: Autonomy and competencies for the prescription of medicines and/or request of tests; Corporate policies that undermine the full exercise of nursing; and Transformation of health and nursing care in Primary Health Care. Conclusion: The prescriptive practice by nurses integrates health care and has been defended by the institutions that represent the category. It emerges as an important element of advanced practice and in the transformation of care in the context of health teams.


Introduction
Nursing has been highlighted as the profession with the greatest tendency to develop in the 21st century. In terms of its institution as a profession, it has advanced more in some countries (1) and less in others, especially in developing countries, such as in Latin America and Brazil (2) .
Nursing has great importance in the process of caring, raising needs and meeting them in the light of the social determinants of the health-disease process. It is important to note that, according to a report from the Pan American Health Organization (PAHO), 60% of the workforce in the health area consists of nursing staff, with about 20 million nurses distributed worldwide, and ¼ of that contingent is in the region of the Americas.
However, in Latin America, there are 15 nurses for every 10,000 people, when the expected is at least 23 professionals for this population (2) . This also highlights the shortage of this professional in health systems for political, ideological and cultural issues.
Besides the shortage of these professionals, they also have not developed the provision of care in a holistic and comprehensive way, given that corporate policies tend to inhibit or hinder the exercise of nursing. Among the most emblematic issues, there is the medication and test prescription, an important and common practice in Primary Health Care (PHC), which the medical category has made efforts to discourage or inhibit. However, it is one of nurses' attributions, especially in view of those common conditions or needs of the community (3) .
There are few studies in the literature that include medication prescription. In the United Kingdom (4) , United States (5) and Canada (6) it is a duty of this professional to fully assist the users, which includes the prescriptive practice. However, in Brazil, this is still undefined, and there are doubts and controversies about the ethical, legal and institutional bases for the practice of prescribing medicines and requesting tests, when performed by nurses (7) . In terms of knowledge gaps, there are few studies analyzing medication prescription by nurses in the context of advanced practice (8) , although this is an important issue to be addressed in order to train and motivate the nurses on this issue in PHC, in Brazil.
PAHO has commissioned an inquiry into the advanced nursing practice and has included the prescription of tests and medications (8) . The transformation of nursing care is a sine qua non for advancing the profession and improving the quality of health services in the country.  Guidelines. Its performance transcends the disciplinary and/or regulatory nature; it is ahead of the movements that aim at the transformation and empowerment of Brazilian nursing (9) . The documents were selected by quality criteria (10) that encompass authenticity (primary document), After collection, the data were organized according to the origin and type of the document; then, they were systematized into analysis categories.
For the analysis, we followed the methodological guidelines of content analysis, thematic modality: pre-exploration of the material or floating readings of the corpus; selection of units of analysis (or units of meanings); categorization process and subcategorization (11) . The units of meanings were

Figures 1 and 2 characterizes the 62 documents,
considering the saturation criterion and taking into account the document type, date, location and sequential coding.         (4) . The authority to prescribe medications contributes to the expansion of nurse's autonomy and is among the characteristics of advanced practice nurses (12) .
The movement against the prescriptive action of been an improvement in care and a great benefit to the community, especially in rural areas (14) .
In conformation of a new model of care guided by the principles and guidelines of the SUS, which has Family Health as a priority strategy for Primary Health Care, the nurse assumes a prominent role, since they receive attributions that contribute to the universal access and coverage of health services (15) . Throughout the world, team care has been considered as paramount for primary quality care (16) .
Since 2013, PAHO has also signaled the strengthening of health systems in order to progressively increase the quality and provision of care aimed at meeting the basic needs of the human being.
PAHO's intention is to give autonomy and support to collaborative multi-professional PHC teams based on established models of care and to maximize the scope of practice of each profession by its own competence, including advanced practice nurses (8) .
One of the major concerns of health systems today is cost reduction. One of the strategies to achieve this goal is redesigning the functions among health professionals.
In this sense, the nurse has been called to expand their functions. Thus, it is believed that, when nurses become prescribers, they enhance patients' access to medications and increase the availability of prescribing professionals in health services (17) . However, it is advocated that the prescription of medicines by nurses, by increasing the access of drugs to users, is not on the order of normative access to the rule of law, but the aspect of the comprehensiveness of care that is a prerogative to that rule of law. It cannot be conceived that the user does not have full access, when there is the prerogative of the right instituted and the ministerial normalization.
A study carried out with nurses of the Family Health strategy in Campina Grande-PB on prescription training revealed that only some of them felt prepared and pointed out the Pharmacology discipline as one that could offer support to this practice (18) . Therefore, even though the  (19) .
The study advances in systematizing and demonstrating the convincing argumentation of the representative entities diluted in many disputes, but directed to the category, since the discussion of medication prescription by nurses should be aligned with its primary purpose that is the user and comprehensive care, which is necessary and important for PHC. We suggest other studies that, besides the thematic analysis carried out, deepen the analysis of the argumentative repertoire as analysis of rhetoric.

Conclusion
In