SciELO - Scientific Electronic Library Online

vol.31 issue3Elaboration and validation of a reader on childhood diarrhea prevention author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand




Related links


Acta Paulista de Enfermagem

Print version ISSN 0103-2100On-line version ISSN 1982-0194

Acta paul. enferm. vol.31 no.3 São Paulo May/June 2018 


Strategies to enhance the profession of nursing as a key partner in improving primary care across the hemisphere

PhD, APNP, FAAN Joyce A. Pulcini1 

DScN, RN Carol S. Lang1 

1001George Washington University School of Nursing, Washington, D.C., USA

For years now, the World Health Organization (WHO) has called for improved primary health care to solve patient needs and for an increase in more qualified health care practitioners to deliver this care (Lawn, et al, 2008). Nurses deliver 90 percent of all healthcare services worldwide, and make up over 80 percent of the global healthcare workforce (Benton, 2015; Davis, 2017). In Latin America and the Caribbean (LAC) primary health care is greatly needed especially in rural and underserved areas (PAHO, 2014). The Nursing Now campaign is built up on the Triple Impact Report which found that as well as improving health globally, empowering nurses will improve gender equality (since the vast majority of nurses are still women) and support stronger economies (All Party Parliamentary Group on Global Health, 2016; ICN, 2018).(1-14)

The Pan American Health Organization (PAHO) in a 2013 declaration called for nurses with advanced training to help meet these primary health care needs (PAHO, 2013) and most recently reiterated this focus in a new publication, Expanding the roles of nurses in primary health care (PAHO, 2018). These nurses must be educated as must nursing schools begin to prepare nurses in these advanced roles. One has to ask, what are the barriers to educate nurses to fill these needs in LAC? Zug, Cassiani, Pulcini and others (2016) surveyed key informants in LAC and found that the role of the APN has just begun or is not yet well implemented or understood in Latin America. While many know about Advanced Practice Nursing roles, others have less knowledge and could benefit from more information and advocacy strategies. Strategies for implementing the APN role have been suggested using to the PEPPA framework by Bryant-Lukosius. (Oldenburger, Cassiani, Bryant-Lukosius, et al, 2017).(5,7,14)

In Latin America, nurses in many areas have sustained low wages and subsequent low status compared to other health care professionals such as physicians. Physician programs have many applicants and many young women often choose this field over nursing. Another issue is the relative lack of status for clinical roles vs administrative roles. Clinical ladders are common, so when a nurse becomes more educated, she or he is likely to move into administration or teaching rather than advanced clinical practice. Physicians tend to dominate in the health professions so nurses do not enjoy the same status. While administrative roles and teaching provide an important basis for improved nursing practice, clinical practice also needs to be valued in order to raise the status of the profession.

In the U.S., universities and other academic institutions have faced a similar growing challenge to provide primary care to patients in rural and underserved areas (Bodenhemer & Bauer, 2016). But, in the US, part of the solution is to increase the number of highly qualified Advanced Practice Nurses (APNs) to meet the complex primary health care needs of diverse populations. In addition, many higher education institutions have responded to an increasing need to shift from hospital-based, specialty nursing education to preparing staff nurses for primary care nursing roles (Macy Foundation, 2016). These changes call for nursing education programs to expand their curricula and incorporate innovative educational approaches to facilitate experiential learning, build skills and enhance knowledge for basic and advanced practice nursing within the context of a global community.(9,10)

Over the years since the APN roles were introduced in the U.S. the status of nurses at all levels has risen as have wages for nurses. Nursing has been the most trusted profession for many years in the U.S. Many young men and women choose nursing over medicine acknowledging the value of the nursing profession. While clinical ladders exist, more and more nurses choose to stay at the bedside or in primary care practices with more education as opposed to moving into higher administrative roles. Faculty shortages in educational institutions educating nurses are well known (AACN, 2017) and salaries of faculty tend to be lower than those of highly skilled clinicians in hospitals and primary care. The IOM Report published in 2011, The future of nursing: Leading change, advancing health, called for a rise in the educational level of all nurses in the U.S. from technical nurses to doctorally prepared nurses as well as increased scope of practice for nurses.(6,10)

One solution to improve clinical nursing in Latin America is to increase the exchange of information across the hemisphere. Currently, an unprecedented interest exists in transnational Academic Global Partnerships in which U.S. schools of nursing are creating institutional partnerships with universities and affiliated teaching hospitals overseas. These international academic partnerships offer unique opportunities for students to engage with peers, health professionals, experts and local citizens in shared learning environments, evidence-based clinical practice, and research. Students and faculty mutually benefit from shared expertise, resources and collaboration with international educators and nursing leaders, which advance nursing practice globally.

The concept of collaborative institutional partnering is not new. Many colleges and universities may lack the resources and expertise to achieve “global reach” and therefore, seek to establish linkages with overseas institutions. Public Private Partnerships (PPP) is another example in which institutions of higher education in wealthy countries have partnered with institutions in low and middle-income countries in various parts of the world.

Given the importance of addressing the unmet needs in primary care, faculty and nursing programs must examine how they can specifically use collaborative academic partnerships with overseas institutions to prioritize advanced nursing education and within the context of a global community. What is needed is a framework for the development of sustainable international partnerships with measurable, defined objectives, goals and impact.

Another strategy is to partner with key nursing and political leaders to begin to implement the Nursing Now campaign in LAC. Engaging key partners beyond nursing such as Ministries of Health and Education as well as political leaders to advocate for this valuable profession can parallel the success that the Future of Nursing report effected in the U.S. The Pan American Health Organization has begun this work by its 2013 declaration and by bringing together nurses and others from across the continent to solve the problems of primary care for LAC (PAHO, 2013). Stakeholders across the continent can be mobilized to move the profession forward in dynamic ways. Nurses are a key part of the solution in solving the primary health care needs of populations. Their power and influence should be unleashed so that nursing talent can be maximally utilized across Latin America and the Caribbean.(12)


1. . American Association of Colleges of Nursing (AACN). Nursing faculty shortage. Washington, D.C.: AACN; 2017. [citado 15 de maio de 2018]. Disponível em: [ Links ]

2. All Party All Party Parliamentary Group on Global Health. Triple impact: How developing nurses will improve health, promote gender equality and support economic growth. London, APPG; 2016. [citado em 15 de maio de 2018]. Disponível em: ]

3. Benton D, Pérez-Raya F, González-Jurado MA, Rodríguez-López ME. Keeping pace with an ever-changing world: a policy imperative. J Nurs Regul. 2015; 6(1): 20-4. [ Links ]

4. Bodenheimer T, Bauer L. Rethinking the Primary Care Workforce - An expanded role for nurses. N Engl J Med. 2016;375(11):1015-7. [ Links ]

5. Davis, S. (2017, Dec. 6). Why nurses are the unsung heroes of global health. Sheila Davis’s blog, Global Nursing Voices. [Internet] [cited 2018 Jul 7]. Available from [ Links ]

6. Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington (DC): National Academies Press (US); 2011. [ Links ]

7. International Council of Nurses (ICN). Nursing now. [Internet] London: ICN; 2018. [cited 2018, Jul 7]. Available from [ Links ]

8. Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M. Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet. 2008 ;372(9642):917-27. [ Links ]

9. Larson T, editor. Registered Nurses: Partners in transforming primary care. Recommendations from the Macy Foundation Conference on Preparing Registered Nurses for Enhanced Roles in Primary Care, Atlanta, Georgia: Josiah Macy Jr. Foundation; 2016. [Proceedings of a Conference on Preparing Registered Nurses for Enhanced Roles in Primary Care]. [ Links ]

10. Oldenburger D, De Bortoli Cassiani SH, Bryant-Lukosius D, Valaitis RK, BaumannA, Pulcini J, Martin-Misener R. Implementation strategy for advanced practice nursing in primary health care in Latin America and the Caribbean. Rev Panam Salud Publica. 2017 Jun 8;41:e40. [ Links ]

11. Organização Pan-Americana da Saúde (OPAS). Expanding the roles of nurses in primary health care. Washington, D.C.: OPAS; 2018. [citado em 15 de maio de 2018]. Disponível em: ]

12. Organização Pan-Americana da Saúde (OPAS). Resolution CD52.R13 Human resources for health: increasing access to qualified health workers in primary health care-based health system [Internet]. Washington, D.C.: OPAS; 2013. [citado em 22 de julho de 2015]. Disponível em: ]

13. Organização Pan-Americana da Saúde (OPAS). Strategy for universal access to health and universal health coverage [Internet]. Washington, D.C.: OPAS; 2014. [citado em 22 de julho de 2015]. Disponível em: ]

14. Zug K, Cassiani S, Pulcini J, Bassolabre-Garcia A, Aguirre-Boza F, Park J. Advanced practice nursing in Latin America and the Caribbean: Regulation, education and practice. Rev Lat Am Enfermagem. 2016;24:e2807 [ Links ]

Creative Commons License  This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.