Advanced Practice Nursing in Brazil: how are we and what is missing?

Enfermería de Práctica Avanzada en Brasil: ¿cómo vamos y qué nos falta?

ABSTRACT

Objective:

To reflect on the role and initiatives of the Brazilian Nursing Association (ABEn) and the Federal Nursing Council (Cofen) in the development, recognition, and regulation necessary to implement advanced practice nursing (APN) in Brazil.

Method:

This is a theoretical-reflective essay resulting from the roundtable discussion entitled “Regulation and recognition of advanced nursing practices in Brazil: how are we and what is missing” held in May 2021, at the III International Symposium on Adult Health.

Results:

ABEn and Cofen are strategic partners to define the areas of activity of this specialization in Brazil. Nursing organizations are responsible for defining professional profiles and curricula, advanced practice nursing conditions, and adequacy of existing graduate courses aiming at technical support, political leadership, regulation, and construction of an APN foundation in Brazil.

Conclusion:

Brazil must broaden the national debate on APN, define a training model for it, and articulate efforts with all its strategic partners to build a theoretical, political, and labor framework for advanced practice nurses’ full professional practice.

DESCRIPTORS
Advanced Practice Nursing; Nursing; Health Systems

RESUMEN

Objetivo:

Reflexionar sobre el papel y las iniciativas de la Asociación Brasileña de Enfermería (ABEn) y del Consejo Federal de Enfermería (Cofen) en el desarrollo, reconocimiento y regulación necesarios a la puesta en práctica de Enfermería de Práctica Avanzada (EPA) en Brasil.

Método:

Ensayo teórico-reflexivo a partir de la mesa redonda titulada “Regulación y reconocimiento de la enfermería de práctica avanzada en Brasil: ¿Cómo vamos y qué nos falta?”, celebrada en mayo de 2021 en el III Simposio Internacional de Salud del Adulto.

Resultados:

Es evidente que la ABEn y el Cofen son socios estratégicos para definir las áreas de actuación de esta especialización en el país. Las responsabilidades de las organizaciones de Enfermería consisten en definir el perfil profesional, el currículo, las condiciones para el ejercicio de las enfermeras de práctica avanzada, la adecuación de los cursos de posgrado existentes, con miras al apoyo técnico, liderazgo político, regulación y construcción de bases para la EPA en el país.

Conclusión:

Es necesario ampliar el debate sobre la EPA en Brasil, definir el modelo de formación y articular esfuerzos con todos los socios estratégicos, con el fin de construir un marco teórico, político y laboral para el pleno ejercicio profesional de los enfermeros de práctica avanzada.

DESCRIPTORES
Enfermería de Práctica Avanzada; Enfermería; Sistemas de Salud

RESUMO

Objetivo:

Refletir sobre o papel e as iniciativas da Associação Brasileira de Enfermagem (ABEn) e do Conselho Federal de Enfermagem (Cofen) no desenvolvimento, reconhecimento e regulamentação necessários à implantação da Enfermagem de Prática Avançada (EPA) no Brasil.

Método:

Ensaio teórico-reflexivo resultante da mesa-redonda intitulada “Regulamentação e reconhecimento das práticas avançadas em enfermagem no Brasil: Como estamos e o que falta?”, realizada em maio de 2021, no III Simpósio Internacional de Saúde do Adulto.

Resultados:

Fica evidenciado que a ABEn e o Cofen são parceiros estratégicos para definição das áreas de atuação desta especialização no país. As responsabilidades das organizações da Enfermagem consistem em definir o perfil profissional, o currículo, as condições para o exercício dos enfermeiros de prática avançada, adequação dos cursos de pós-graduação existentes, com vistas ao apoio técnico, liderança política, regulação, regulamentação e construção de bases para EPA no país.

Conclusão:

É preciso ampliar o debate sobre a EPA no Brasil, definir o modelo de formação e articular esforços com todos os parceiros estratégicos, no intuito de construir um arcabouço teórico, político e laboral para o pleno exercício profissional do enfermeiro de prática avançada.

DESCRITORES
Prática Avançada de Enfermagem; Enfermagem; Sistema de Saúde

INTRODUCTION

Technological advances, epidemiological profile changes, health-disease process determinants, population aging, emerging diseases, natural disasters, and disease and pandemic coping have raised concerns about the population’s health and health service coverage and universal access to it.

The World Health Organization (WHO) published an alert in 2020 entitled “Urgent health challenges for the next decade,” highlighting priorities such as fairer health service access, protection against infectious diseases and dangerous products, preparation for epidemics, guarantee of access to medicine, and strategies to invest in professionals protecting the health of the population(¹).

The WHO considers nurses the great driving force of health systems and important agents to ensure care and coverage of access to health services. Thus, WHO declared 2020 the “Year of the Nurse and Midwife” by launching the “Nursing Now” campaign(²).

The actions the WHO envisage aim to strengthen nursing. Among them, we highlight advanced practice nursing (APN), a care model developed since the 1960s by nurses (primarily in developed countries, such as the US, the UK, and Canada) with specialized training and expanded scope of practice which aim to ensure and to expand access to health coverage for vulnerable and remote populations.

According to the International Council of Nurses (ICN), an advanced practice nurse “is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which they are credentialed to practice”(³).

Studies have indicated that countries with consolidated APN recognize nursing professionals both for their quality of care and user satisfaction, with significant impact on cost–benefit analysis(⁴,⁵). Moreover, scientific evidence shows that APN benefits users by reducing chronic disease costs, optimizing health resources, improving the quality of the care provided, and managing chronic conditions, among others(⁶).

Brazil lacks APN training, which requires a master’s program with an extensive clinical activity workload. In addition, regulating advanced practice nursing in the country is to face many difficulties since the Brazilian health system continues to strengthen physician’s hegemony in its organization. However, nurses in Latin American countries perform increasingly complex actions in the face of the health demands of the served population, evincing the potential for expanding their scope of practice(⁷).

Moreover, Brazil may face several challenges to regulate APN, such as understanding its role of action, defining the scope of professional practice, aligning actions with other team members, and regulating and legislating professional practice(⁶).

In this context, we observe movements such as discussion forums among societies, class entities, and government agencies aimed to elaborate strategies to nationally implement an expanded model of practice, especially regarding primary health care(⁸).

There is favorable scenario for the implementation of APN in Brazil by considering the legislative milestones which support this scope of action, such as the Law of Professional Nursing Practice, the National Primary Health Care Policy, resolutions, and opinions issued by the class council, regulating procedures and actions of high complexity; in addition to the evidence- based practice(⁶,⁸).

However, Brazilian municipalities still show disarticulated care between primary and other care levels due to inequalities in service provision, weaknesses/difficulties in their articulation mechanisms, and lack of interlevel dialogue. Professionals also face adversities in dealing with the complexity of the most frequent health problems(⁹,¹⁰), in addition to significant differences in health indicators among regions, with better results in the Brazilian Southeast and South and worst in the North and Northeast(¹¹). APN can contribute to expand health service access and resolution in this reality, in line with the Brazilian Unified Health System (SUS) principles and guidelines.

Based on discussions which began in 2016 among the Federal Nursing Council (Cofen), the Brazilian Nursing Association (ABEn), and the Pan American Health Organization (PAHO), we find a common effort to broaden the dialogue between healthcare providers, training institutions, and other class entities on the need and viability of advanced practice nurses in Brazil, especially in primary health care (PHC). This article aims to reflect on ABEn and Cofen roles and initiatives in the development, recognition, and regulation necessary to implement advanced practice nursing in Brazil.

METHOD

Type of Study

This is a theoretical-reflexive essay which shows APN0 conceptual aspects and ABEn initiatives to problematize the issue and discuss the possibility of accommodating APN within the structure of current residency and professional master programs to promote their equivalence with APN training model and requirements and Federal Nursing Council initiatives to build the political-institutional framework for its implementation in Brazil.

These aspects were presented at a roundtable discussion entitled “Regulation and recognition of advanced nursing practices in Brazil: how are we and what is missing?” held on May 27, 2021, at the III International Symposium on Adult Health, which had the participation of professionals involved with the theme; representatives of nursing entities—such as ABEn, Cofen, and specialty societies—and of academia and healthcare, discussing APN implementation in Brazil.

Below we show how ABEn and Cofen see the reflections from this roundtable discussion to contribute to the construction of bases to implement APN in Brazil.

The Role of Aben in the Discussion and Construction of the Bases for Apn in Brazil

Talking about the role of ABEn in regulating APN requires resuming ICN and PAHO indicators and tracing a brief history of the beginning of these discussions in Brazil.

ICN(¹²) uses the term Advanced Practice Nursing (APN), translated into Portuguese and Spanish as EPA, and recommends a master’s degree as the entry level for this practice. In its 2009 publication, ICN shows the training, technical-scientific skills, and professional regulation necessary for APN: advanced educational preparation; formal recognition of educational programs preparing nurses for accredit or approval in advanced practice nursing; a formal licensing, registration, certification, and accreditation system; the nature of the practice; research integration, education, practice, and management; high degree of professional autonomy and independence; case management; advanced health assessment, decision-making, and diagnostic reasoning skills; recognized advanced clinical competencies; consultation for health providers; and program planning, implementation, and evaluation.

It also mentions the need for regulatory mechanisms and country-specific regulations supporting the action of nurse practitioners/APN, i.e., the right to diagnose; the authority to prescribe medications and treatment, refer patients to other professionals, and admit patients to the hospital; legislation to confer and to protect the title “nurse/advanced practice nurse”; legislation or some other form of regulatory mechanism specific to advanced practice nurses; and officially recognized titles for nurses preparing to work in advanced practice(¹²).

PAHO, in turn, recognizes APN as an effective strategy to expand access to health coverage in Latin American and Caribbean countries, approving resolution CD52.R13 in September 2013, which directs countries to prioritize PHC public policies, train their workforce, and increase the number of advanced practice nurses to primary health care support systems(¹³,¹⁴).

These are important indicators to discuss and to regulate APN worldwide(¹⁵) which, Brazilian representative entities such as ABEn and Cofen also discuss.

ABEn has built the scientific, political, and social bases for Brazilian nursing, advocating good training, the development of nursing knowledge, and research and professional practice focused on the population’s health needs and based on scientific evidence. This discussion has undeniably contributed to defend and to consolidate the Unified Health System (SUS).

It is from this place that we place ourselves, highlighting the significant role ABEn plays in this discussion and collective construction of APN in Brazil. Thus, below we show both administration presidents’ initiatives.

From 2015 onward, there were important initiatives to collectively discuss APN in Latin America, with the active participation of ABEn—at the time under the presidency of Prof. Angela Maria Alvarez (2013–2016)—along with other Latin American nursing organization representatives in workshops and meetings in the United States and Canada which widely debated universal access, universal health coverage, and APN.

We highlight the participation of ABEn in the 2015 XII Conference on Nursing Education, promoted by the Asociación Latinoamericana de Escuelas y Facultades de Enfermería (ALADEFE) with the theme “Advanced Practices in Nursing in Ibero-America,” and the constitution and coordination of a working group in partnership with CAPES nursing, to propose guidelines for APN in primary health care in Brazil, with professors from the most prestigious public nursing universities in Brazil.

This group produced its reflection by considering that APN could contribute to PHC meeting universal coverage, realizing that SUS already has universal access prerogatives and that, in Brazil, advanced practice nursing is complementary to other measures to cope with the scarcity of healthcare providers, especially of physicians.

In October 2015, PAHO promoted a seminar entitled “Nursing training policies for advanced practices in SUS,” aiming at undergraduate and graduate nursing course coordinators, to discuss policies to train human resources in primary care advanced practice nursing and envision possibilities for graduate nursing training to meet the demands of advanced primary care practices.

The discussed perspective considers that the proposal to expand the scope of nursing does not mean filling spaces and jobs of no interest to physicians, but rather to contribute to ensure access to good primary care. Nurses would develop advanced practice interprofessionally, thus recognizing professional complementarity and interfaces, i.e., emphasizing clinical practice in an interprofessional, articulated, and collaborative perspective between health unit teams and the health care network services.

In November 2015, ABEn and Cofen attended a PAHO meeting on APN held in Washington-US, which aimed to rethink the term “advanced practice nursing”; to reflect on an APN proposal for Brazil which integrated SUS; and to analyze primary care nursing contributions within broader public policies. These entities, in turn, undertook the structuring of a work plan in cooperation with PAHO to devise a preliminary guideline to be presented and discussed with the Brazilian Ministries of Health and Education.

This document, entitled “Advanced practice nursing training in primary health care: proposal for Brazil,” produced by ABEn, Cofen, CAPES Nursing Coordination, the General Coordination of Health Residences from the Ministry of Education, and PAHO technicians, was delivered to the Ministry of Health in December 2015. That document proposed expanding the scope of nursing (focused on PHC and strengthening SUS) and addressing the concept and scope of APN, the Brazilian health context which justifies the relevance of APN in PHC, the context of the Brazilian nursing workforce and need for training, advanced practice nurses’ profile and competencies, the development of a proposal to train advanced practice nurses, and the regulation of professional APN practice in Brazil.

The theme continued to be widely discussed in 2016: in a meeting ABEn held with the Secretariat of Labor Management and Health Education of the Ministry of Education; in a workshop entitled “Nursing Practices in Primary Care” at a Rede Unida congress attended by PAHO, ABEn, and the Secretariat of Labor Management; in a meeting of the Advanced Practice Nursing Summit in the USA, which discussed developing APN competencies in Latin America to contribute to universal health(¹⁴); and at the 67th Brazilian Nursing Congress, with a lecture given by the ABEn president on APN perspectives with professional masters programs.

Moreover, in March 2016, PAHO organized a workshop to discuss expanding the scope of advanced practice nursing, its resolution, and care training with emphasis on primary care; mobilize actors to reflect on nursing education and practice; discuss perspectives for nursing education and practice with a focus on primary care access and resolution and priority care lines; and systematize contributions to qualify nursing training and practice actions to be further developed by interinstitutional working groups of nursing education.

Discussions in the working group progressed since training advanced practice nurses should develop not only an expanded clinical practice but also leadership skills, autonomy, investigation, and evidence-based decision-making to change practices and expand power spaces. However, the health training model, especially on nursing, does not include the APN training model of countries such as Canada, USA, and England. Many discussions followed to try and present a hybrid proposal that would associate residency with a professional master’s degree, considering the high clinical workload in graduate nursing residency and master’s program training, preparing them for research, leadership, and management(¹⁶), which needs further discussion.

The topic is again discussed by ABEn, in 2021, under the presidency of Prof. Sonia Acioli de Oliveira (Management 2020–2022) during the international Advanced Practice Nursing Workshop in April 2021. Speakers offered an APN overview in the world and in Brazil, and reflections which need to be considered in the debate on advanced practice nursing in Brazil: 1) define the scope of practice, their role in health teams, scenarios in which they will act, whether it would be an alternative to act in remote places and how they would be fixed in these places; 2) define the professional profile of advanced practice nurses (who should have a high degree of autonomy and independent professional practice); ability to manage cases via clinical decision-making and integrate research, management, and education actions, and provide audit; 3) base actions on the population’s health needs and epidemiological profiles and on the recognition of the role SUS has; 4) the need for nurses to have solid training; for this, it is necessary to define what training is required and how it would occur. In addition, it is essential to invest in teachers training who will train advanced practice nurses; 5) define competencies which advanced practice nurses should develop; and 6) define their regulation, career plan, and salary cap.

In this event, the Red APN LatinA vice president mentioned that APN needs specific regulation for its recognition, but it was not necessary to change the Brazilian Law of Professional Nursing Practice (Law 7498/86). Moreover, the Brazilian National Primary Care Policy(¹⁷) presents specific nurse attributions, such as nursing consultations, procedures, risk stratification; preparation of a care plan for people with chronic conditions; request for complementary examinations; prescription of medications according to protocols; forwarding, when necessary, users to other services, etc.

Another important ABEn initiative was launching a REBEn thematic issue in 2021, entitled “Advanced Practices in Nursing,” to be published in 2022, to enable researchers to disseminate knowledge on innovation and advancement, with emphasis on teaching, care, and management studies, both in hospitals and in the community.

Red APN Latina, founded in 2020, has sought to further develop the regulation discussion in Latin America and Brazil and is currently developing a multicenter study in 14 countries. In Brazil, the study aims to analyze the advanced practice nursing competencies currently developed by nursing professionals in different health care contexts. This study has the participation of ABEn and the support of Cofen for its development throughout Brazil and will be important to make APN diagnosis in Brazil and Latin America.

The description of ABEn actions on APN in Brazil shows that it has always had and still has a prominent role in everything related to nursing training, research, and professional practice. However, it is important to consider that ABEn has no role in its regulation as it is not a regulatory association. Even so, it participates in this movement, collaborating to the debate on APN and its construction in its various instances.

The Role of Cofen in Regulating Advanced Practice Nursing

Cofen and its Regional Nursing Councils were created on July 12, 1973, via Law 5,905. Together, they form the Cofen/Regional Council System, responsible for standardizing and supervising the practice of nurses, technicians, and nursing assistants, ensuring the quality of the provided services and compliance with the Law of Professional Nursing Practice throughout the country in defense of autonomy, scientific growth, and good professional practice.

Cofen has discussed APN since 2016, having created the Commission on Advanced Nursing Practices from a joint effort to prepare, in 2015, with CAPES, ABEn, and MEC representatives, a document on the feasibility of organizing a policy proposal for training and fixating advanced practice nurses, incorporating new professional competencies, expanding their health care and nursing autonomy.

Since its creation, this committee has produced studies aimed at actions to regulate and train advanced practice nurses since Cofen has legal responsibilities related to the qualified exercise of nursing professionals throughout the country. A prominent action this commission proposed was a national research project entitled Nursing Practices in the Context of Primary Health Care, aimed at knowing the reality of nurses’ actions in the first level of health care, how they developed their practices in the country, what new competencies they have assumed and recognized as innovative, and what difficulties they face in this practice. The research coordinated by the Center for Public Health Studies at the Universidade de Brasília obtained the participation of all regional state councils and partner universities which locally executed its directives. Its results are in the final phase of analysis for further national dissemination.

Another highlight of Cofen disseminating APN knowledge was the participation of the Commission on Advanced Practices, guiding the theme of its creation in strategic events, such as the 2018 12th Brazilian Congress of Collective Health, held in Rio de Janeiro, and the 2019 National Health Conference.

The Cofen Commission on Advanced Practices, which brings together primary care and women’s health specialists, municipal health managers, teachers, and service nurses, has positively responded to the demands from national and international public and private institutions so agencies show the possibility of implementing advanced practice nurses in Brazil who are consistent with population’s needs. Moreover, the commission participates in discussions in political and university spaces, spreading the theme among teachers, education technicians, and students since it recognizes the importance of bringing qualified information to answer doubts about who is and what nurses do in advanced practices.

DISCUSSION

The Brazilian nursing workforce totals 2,756,699 professionals, of which 438,407 are nursing assistants; 1,688,798, nursing technicians; 629,160, nurses; and 334, obstetricians(¹⁸). This professional contingent faces unevenly distributed job vacancy and nursing training facilities across the country. Cofen has worked jointly with CAPES to train professionals in strategic areas, such as systematization of nursing care (SNC), to strengthen and value their practice and nursing process in care spaces.

ABEn, in turn, via the Permanent Nursing Practice Systematization Commission (PNPSC/COMSISTE), has invested in permanently training nurses to systematize nursing care and establish actions to effectively implement the nursing process in professional practice and standardized language in nursing data documentation and information systems(¹⁹). These Cofen and ABEn initiatives provide more favorable conditions for the development of APN in Brazil.

The large sanitary wants which persist in more Brazilian remote regions imprint varied perspectives for the performance and autonomy of nurses’ actions. This aspect led the Cofen Commission on Advanced Practice Nursing to identify the Brazilian regions with the greatest need of advanced practice nurses adequately trained in this professional practice and capable of excellent performance, especially regarding the expansion of vulnerable populations’ service access and health action coverage since these are the professionals working in the initial and main contact with users in first health care level units.

Another important aspect of the Cofen actions to implement advanced practice nursing in Brazil are the political negotiations it has gradually constructed with strategic actors, such as PAHO, the National Council of Health Secretaries, the National Council of Municipal Health Secretariats, and higher education institutions, to align discussions on the recognition and guidelines to introduce expanded roles to Brazilian nurses. One requirement to certify these professionals as advanced practice nurses is strong clinical training in partner universities and municipal health units. In 2020, Cofen joined the Red de Enfermería Práctica Avanzada de Latinoámerica y el Caribe as a strategic partner to represent Brazilian nursing(²⁰).

An important cooperative action was a 40-hour internship in Andalusia, Spain, for Cofen Commission on Advanced Practices, the Ministry of Health, and ABEn professionals which PAHO promoted in 2018 together with the Andalusian School of Public Health. Professionals exchanged experiences and knowledge on advanced nurses’ practice in the Spanish Health System, from primary to specialized care, including case- management and liaison nurses’ actions. This partnership has contributed to positive dialogues between these institutions, with the participation of professors from the Andalusian School of Public Health and of advanced practice nurses from the Netherlands, Canada, USA, France, and Portugal in Brazilian nursing council congresses, which brought many contributions despite the COVID-19 pandemic, including international seminars promoted by the working group of the Commission of Advanced Practice of Cofen, and PAHO/WHO and the Collaborating Center of the University of São Paulo at Ribeirão Preto College of Nursing, in Brazil.

Another result toward expanding Brazilian PHC nurses’ autonomy was elaborating and disseminating guidelines to elaborate primary care nursing protocols, with specialists encouraging and supporting regional councils to organize protocols in Brazilian states along professionals from state and municipal health departments, higher education institution representatives, and specialists from different areas. Moreover, Cofen has offered PHC nurse guidelines to strengthen their work process and autonomy. In 2018 and 2019, its Commission on Advanced Practices offered two courses on the development of PHC nursing protocols to Mercosur countries which resulted in good international cooperation.

This initiative is already in its third model edition, which has brought good perspectives to give agility to care flows and decision making and standardize care, ensuring better conditions for the development of PHC nurses’ work processes.

The 2021 ABEn International Workshop strengthened this debate by offering an overview of APN in the world and in Brazil, its experiences, positions, limits, challenges, roles, advanced practice nurses’ desired profile, and training indications.

At Red APN LatinA meetings(²⁰), all its members (from different countries) recognize the need for a clear and in-depth understanding of the role and competencies of this nursing professional to advance its local implementation and claim that nursing leaders must “promote a shared vision of professional development which promotes cohesion and collaboration among professionals and enable them to advance in an organized way, supporting and negotiating as one voice in the search for the same goal.”

The APN discussion in Brazil and Latin America should be held from a critical perspective according to the needs of each region and the organization of municipal health systems, with expanded discussions on an education model which is appropriate to expanding the scope of clinical practices and nursing. Many initiatives are underway, with different institutions promoting meetings and workshops with the participation of ABEn, Cofen, CAPES, CNPq, and other stakeholders—such as Red APN Latina—which have shown the need to expand the scope of professional practice and a training which corresponds to reality and the role nurses play in the Brazilian health system.

We clearly see the difficult context which Brazil currently experiences not only due to the COVID-19 pandemic but also because of the severe political, social, and economic crisis from which stems the heavy attacks to historically conquered social policies. However, we need to further develop the debate.

Recent evidence suggests that understanding APN, nurses’ scope of action, and how they are part of the health system should be the first step to implementing APN in Brazil(⁴), and that its development as support for initiatives of “universal access to health and health coverage” needs to be based on strong legislative support, a solid educational structure, and continuing education(²¹).

Given this, the various initiatives shown here highlight the role of ABEn and Cofen as Brazilian nursing representatives further developing the debate and building the political, theoretical, and training bases necessary for advanced practice nursing.

The aforementioned “Nursing training of advanced practice in primary health care: proposal for Brazil” was an important initiative of Brazilian nursing representatives. We propose to continue in this collective construction, helping to produce curricular guidelines to train and support advanced practice nurses, monitor the implementation of APN, and evaluate its impact and process.

CONCLUSION

The leading role of Cofen in bringing the relevance of advanced practice nursing and nurses to the national discussion and its professional regulatory and supervisory role, as well as the role of ABEn within political articulation and the constitution of guidelines for nursing education in Brazil, evince that Brazilian nursing representatives have developed important initiatives aimed at political-labor consolidation and foundation construction to constitute APN in the country.

It is necessary to broaden the debate on APN in Brazil and define a model to train specialists in specific areas to meet SUS needs and contribute to the development of nursing in the expansion of access and health coverage for the entire population. Effort articulation with all strategic partners is fundamental since it is insufficient to have advanced practice nurses without a theoretical, political, and labor framework for their full professional exercise.

It is still necessary to identify potentialities and possibilities of action for nurses who already gather professional experience and want to train in functions which will expand their practice scope, case management and follow-up; clinical care innovation; interprofessional leadership; health outcome investments and evaluation; and regulatory mechanisms for advanced practice nurses. This is a joint construction of senses and meanings, unveiling itself in a new area of action for nurses in Brazil.

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Edited by

ASSOCIATE EDITOR

Lilia de Souza Nogueira

Publication Dates

• Publication in this collection
  18 July 2022
• Date of issue
  2022

History

• Received
  14 Oct 2021
• Accepted
  01 Apr 2022