Advanced practice nursing in Latin America and the Caribbean: context analysis

Abstract

Objective

To describe the factors that can influence the implementation of Advanced Practice Nursing (APN) in contexts of Latin American and Caribbean countries.

Methods

This context analysis was performed in October 2017 by means of a scoping review. The search for studies was performed in databases and portals of national and international theses and dissertations. The sample included nine studies based on the analysis and correlation between the findings of these publications on APN in Latin America and the Caribbean and the contextual spheres proposed by Hinds and their specificities.

Results

In Latin American and Caribbean countries, were defined the following factors among those favoring the implementation of APN: particularities of APN in Latin America and the Caribbean; the challenges and potential of APN in Latin America and the Caribbean; perspectives of APN in Latin America and the Caribbean; and legislations of APN in Latin America and the Caribbean.

Conclusion

APN in Latin America and the Caribbean has the potential to be implemented, but specific barriers are still faced in the different realities investigated.

Advanced practice nursing; Latin america; Caribbean region; Nursing research

Resumo

Objetivo

descrever os fatores que podem influenciar a implantação da PAE nos contextos dos países da América Latina e Caribe.

Métodos

Trata-se de uma análise de contexto realizada em outubro de 2017 mediante uma scoping review. A busca dos estudos deu-se nas bases de dados e nos portais de teses e dissertações nacionais e internacionais. A amostra compôs-se de nove pesquisas, a partir da análise e correlação dos achados dessas publicações sobre a Prática Avançada em Enfermagem na América Latina e no Caribe para com as esferas contextuais propostas por Hinds e suas especificidades.

Resultados

Dentre os fatores presentes nos contextos dos países da América Latina e Caribe que favorecem a implantação da Prática Avançada em Enfermagem, delimitou-se: as particularidades da Prática Avançada em Enfermagem na América Latina e no Caribe; os desafios e as potencialidades da Prática Avançada em Enfermagem na América Latina e no Caribe; as perspectivas da Prática Avançada em Enfermagem na América Latina e no Caribe; e as legislações da Prática Avançada em Enfermagem na América Latina e no Caribe.

Conclusão

Inferiu-se que a Prática Avançada em Enfermagem na América Latina e no Caribe apresenta potencialidade de ser implementada, mas ainda há barreiras específicas nas diversas realidades investigadas.

Prática avançada de enfermagem; América Latina; Região do Caribe; Pesquisa em enfermagem

Resumen

Objetivo

Describir los factores que pueden influir en la implementación de la PAE en el contexto de los países de América Latina y el Caribe.

Métodos

Análisis de contexto efectuado en octubre de 2017 mediante scoping review. Se realizaron búsquedas en las bases de datos y los portales de tesis y disertaciones nacionales e internacionales. La muestra consistió en nueve encuestas, basadas en el análisis y correlación de los hallazgos de estas publicaciones sobre Práctica Avanzada de Enfermería en América Latina y el Caribe con los ámbitos contextuales propuestos por Hinds y sus especificidades.

Resultados

Entre los factores presentes en los contextos de los países de América Latina y el Caribe que favorecen la implementación de la Práctica Avanzada de Enfermería, se definieron las siguientes: las particularidades de la Práctica Avanzada de Enfermería en América Latina y el Caribe; los desafíos y potencialidades de la Práctica Avanzada de Enfermería en América Latina y el Caribe; las perspectivas de la Práctica Avanzada de Enfermería en América Latina y el Caribe; y la legislación de la Práctica Avanzada de Enfermería en América Latina y el Caribe.

Conclusión

Se infirió que la Práctica Avanzada de Enfermería en América Latina y el Caribe tiene potencial para ser implementada, aunque aún existen barreras específicas en las diversas realidades investigadas.

Enfermería de práctica avanzada; América latina; Región del Caribe; Investigación en enfermería

Introduction

Advanced Practice Nursing (APN) was structured in the United States of America (USA) initially with nurses trained as a Clinical Nurse Specialist (CNS) with a focus on the hospital setting. Subsequently, a new classification emerged in the 1960s - the advanced practice nurse or Nurse Practitioner (NP), in which care is focused on primary health care (PHC).^(1-3)

For the International Council of Nurses (ICN), APN is the performance of specific and complex activities, and the ability to make decisions independently in order to meet the population needs in health.⁽⁴⁾

The inclusion of APN showed nurses’ relevance by demonstrating that their autonomy promoted greater coverage of care, more efficient care, reduction of costs, effective management activities in line with population demand, credibility and affirmation of the profession.^(3,5)

With a view to providing greater accessibility and quality of care, APN was disseminated worldwide, in Canada in the late 1960s, and in Europe and Asia in the 1980s.^(1,2,5) In Latin America, APN spread only at the beginning of the 21^st century through the formulation of resolutions and research developed in educational institutions.^(1,5-8)

This search for the promotion of APN in Latin American countries occurred due to local socioeconomic needs and, despite differences in the levels of development of these countries, there are still obstacles for achieving quality health care, mainly because of human and material resources deficits.^(5-9)

Thus, the Pan American Health Organization (PAHO) adopted Resolution CD52.R13: Human Resources for Health: Increasing Access to Qualified Health Workers in Systems Based on Primary Health Care-based Health Systems. And, as a continuity, in the following year, was developed the Strategic Plan for Universal Health Coverage focusing on Latin America.^(10,11)

Thus, PAHO understands the importance of training and qualifying nurses with regard to APN. However, the quality of postgraduate courses in Latin America has to be expanded and optimized, as well as the support of nursing institutions and governmental agencies in those countries.^(1,4,10-12)

The aforementioned shows the determination of world institutions in achieving the implementation of APN in Latin American countries with the aim to facilitate the population’s access to health services, offer qualified health care, minimize social inequalities, and value and enhance nursing professionals’ training.^{(1,5,6,8,12,13)}

Therefore, if the development and affirmation of APN in a given locality depends on its context, there must be an understanding of the possible strengths and weaknesses for the easier design of measures that contribute to promotion of APN in Latin America and the Caribbean.

The context is a set of interconnected relations about a fact or scenario and, as a means of analysis, it comprises four interactive levels, namely: the immediate focuses on the present and represents the episode itself; the specific level encompasses the immediate past together with elements that influence the event; the general level involves past and present interactions of events occurring over time; and the metacontext includes the previous with emphasis on the present and highlights the conditions and learnings as a model for the future.⁽¹⁴⁾

Thus, the relevance to know and understand the different contexts (educational, care, social, political) that may influence the implementation of APN in Latin American and Caribbean countries. The clarification of these circumstances will contribute to the discussion on the eventual implementation of APN in the region.

Therefore, was delineated the following guiding question for this study: What factors can influence the implementation of APN in contexts of Latin American and Caribbean countries? And the aim was to describe the factors that can influence the implementation of APN in contexts of Latin American and Caribbean countries.

Methods

A scoping review was conducted as recommended by the Joanna Briggs Institute, since this method includes several databases and catalogs of global theses and dissertations, as well as the gray literature.⁽¹⁵⁾

The search of studies in databases was performed in October 2017, and were used the Boolean operators “AND/OR”: ((Nurse OR Personnel, Nursing OR Nursing Personnel) AND (Advanced Practice Nursing OR Nursing, Advanced Practice OR Practice Nursing, Advanced) AND (Latin America)).

The following databases were used: U.S. National Library of Medicine (Pubmed), Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of science, SCOPUS, Latin American and Caribbean Health Sciences Literature (LILACS), Academic Archive Online (DIVA), Europe E-theses Portal (DART), Electronic Theses Online Service (EThOS), PsycINFO, The National Library of Australia’s Trobe (Trove), Portuguese Open Access Scientific Repository (RCAAP), Theses Canada, Cochrane CENTRAL, Educational Resources Information Center (ERIC), South African National Theses and Dissertations (ETD Portal).

In the selection of studies, were included those addressing some context of APN in Latin America and the Caribbean, available in full and for free. Opinions, letters to the editor and duplicate documents were excluded.

In the selection of publications, were identified 400 studies. After reading titles and abstracts, 391 were excluded because they only mentioned APN, and nine addressed some context of APN in Latin America and the Caribbean. After the full analysis, the nine studies formed the final sample (Figure 1).

Figure 1
Flowchart of the study selection process

The context analysis model was adopted because it enables the dynamic understanding of relationships forming a phenomenon, which leads to an easier comprehension of its dimensions and its occurrence.⁽¹⁴⁾

In the present study, the immediate context refers to direct characteristics of APN in educational and care spheres that contribute to this practice implementation in Latin America and the Caribbean. The specific context includes interpretations of actions performed or not, which can facilitate or accelerate this professional exercise. The general context covers relevant aspects of the past, measures proposed and/or adopted with a view to boost the development of APN. The metacontext evaluates the present and the past in order to investigate elements associated to laws and regulations on APN in Latin American and Caribbean countries.

After the analysis, data were correlated and grouped at each contextual level according to their particularities and presented in subtopics. A graphical representation of interrelated layers was constructed as well.

Results

The final sample of this study included nine studies published between 2001 and 2017. Three^(6,9,16)(33.3%) were published in 2016, two^(5,8) (22.3%) in 2017, and the others in 2001⁽¹⁷⁾ (11.1%), 2013⁽¹⁸⁾ (11.1%), 2014⁽¹⁹⁾ (11.1%) and in 2015⁽¹³⁾ (11.1%). These studies were conducted in Argentina, Bolivia, Brazil, Chile, Colombia, Jamaica and Mexico.

Regarding contextual levels, in the Caribbean, the characterization of APN was identified in the immediate, for example, in nursing professionals’ autonomous attitudes, advanced practices in drug prescriptions and possibilities for the population’s access to health services.^(6,8,16-18)

In the specific context, aspects that strengthen the progress of APN in Latin America and the Caribbean stood out, among which the profile of health professionals’ training, the increase of postgraduate programs, and expansion and appreciation of APN.^{(6,8,9,13,18,19)}

In the general context, the positive interference of APN in Latin America and the Caribbean was evident, especially for the promotion of primary care as a gateway to the health system, the provision of greater access to health services for the poor, optimization of master’s and PhD courses, and the consequent improvement of nurses’ activities in patient care.^{(5,6,8,9,13,16-19)}

The metacontext includes past and present with future perspectives. There were wide regional differences of socioeconomic development between countries in Latin America and the Caribbean, and organizational and political movements in favor of APN, which are factors that influence the implementation of this practice in educational and health systems.^(5,6,8,9,17)

Thus, contextual levels are the following: particularities of APN in Latin America and the Caribbean (immediate context); the challenges and potential of APN in Latin America and the Caribbean (specific context); perspectives of APN in Latin America and the Caribbean (general context); and legislations of APN in Latin America and the Caribbean (metacontext), as shown in figure 2.

Figure 2
Contexts of APN in Latin America and the Caribbean

Discussion

Most studies in the final sample are from recent years, which demonstrates that even though discussions about APN exist since the 1970s, the topic is still incipient and less widespread in Latin America.^(1,17)

The following sub-themes present the findings of this study for an easier understanding of the perspective of APN in Latin America and the Caribbean.

Particularities of APN in Latin America and the Caribbean

In a study⁽⁶⁾ developed with nursing professionals and from their perceptions, was found no clear distinction between the different roles and specific responsibilities of each component of the professional category (nurse and nurse technician).

On the other hand, other studies^(15,17,18) indicated a contrary perception, and APN was associated with nurses who perform care directly, lead, collaborate and cooperate with the health team and users, actively participate in teaching, research, decision making, among others.

These actions are equivalent to those identified by the ICN, which determines professionals’ involvement in research, education, practice and management, as well as their demonstration of autonomy and independence with advanced clinical skills.⁽⁴⁾

Regarding training for APN, this sample contains a Brazilian case in which the specialization course (lato sensu) was reported as a prerequisite for nurses performing their activities.⁽¹⁸⁾ In other studies,^(13,17) the specialization course (lato sensu) is highlighted as a minimum requirement for APN. This aspect differs from global recommendations, since the title is only awarded to professionals with a master’s degree.⁽¹⁷⁾

PHC is a possible scenario of practice of APN.^{(6,8,9,16,17-20)} In this case, emerge the health promotion and prevention, drug prescription, and leadership of the health team.^(8,9,16,17)

In one of the studies,⁽¹⁸⁾ is addressed nurses’ practice in specialized hospital oncology. In this situation, care practices are clinical visits, assistance in performing diagnostic procedures and follow-up therapy, participation in discussions of clinical cases and scientific meetings, development and implementation of protocols for prevention of risks and diseases, teaching of treatment protocols and specific care.

In the hospital setting, APN can supply the lack of a qualified, humanized care based on patients’ individual needs.^(16,18) In PHC, these professionals are seen as a possibility of expanding the population’s access to services.^{(6,8,9,16,17)}

The particularities of APN identified in this study are related to nurses’ specific characteristics recognized globally in this practice that are generally mentioned in the literature. According to the ICN,⁽⁴⁾ such characteristics should be related and defined in discussions of the movements of each country.

Challenges and potential of APN in Latin America and the Caribbean

The challenges for implementation of APN are the training focused on the biomedical model and resistance of other members of the multiprofessional team.^(6,13,18,19)

Regarding nurses’ training, in a study,⁽¹⁹⁾ this professional category considered that teachers do not promote a PHC-oriented teaching and workers are trained based on the hospital-centric model. In this same study, was suggested the participation and support of foreign universities, since these institutions have professionals exercising APN.

The main cause for the multiprofessional team resistance is the lack of definition of each team member’s role. This difficulty can be overcome through integrated work and discussion of clinical cases.⁽¹⁸⁾

The nursing practice in PHC is highlighted as a potentiality in the sample.^{(6,8,9,16,17)} Although the field of public health is heterogeneous across countries because of epidemiological and infrastructure divergences, nurses agree there is strong acceptance of nursing in PHC by the population.⁽¹⁹⁾

In Brazil, a postgraduate course in nursing is a facilitator for APN. In this country, there is a great variety of stricto sensu (master’s) and lato sensu (specialization) programs hence, a favorable scenario for professional qualification.^{(6,13,17,19,20)}

In countries where APN is regulated, such as the US and UK, similar barriers were found. The strategy adopted in these cases was the production of evidence, as it attracted financial and political support that contributed to the maturation of APN. Knowing the successful experiences and taking them into consideration puts all of Latin America and the Caribbean in an advantageous position in order to overcome weaknesses and enhance their strengths.^(9,16,17,19)

Perspectives of APN in Latin America and the Caribbean

Studies^{(5,6,8,9,13,16-19)} point out that APN is not a current reality, but global level organizations seek to introduce it in order to meet the needs related to access and quality of health care and consequently, exert influence in the care process.

Among the perspectives for implementation of APN, were highlighted the insertion and encouragement of nurses’ work focused on prevention and health promotion, especially in rural areas and those of difficult access, since these regions have deficiencies of different etiologies compared to urban localities.^(6,8,16)

These geographical and structural divergences are a result of the poor distribution of human and material resources with greater concentration in cities close to the capital to the detriment of more distant municipalities.⁽²¹⁾

However, when considering the needs of peripheral populations in Latin countries, are sought strategies to meet these deficiencies with the PAHO support.^(1,4,8,9,11) Such an organization encourages the insertion of APN as an important strategy for solving health care coverage problems.^(11,12)

The contribution with insertion of APN in these contexts points to the transition from the biomedical to the biopsychosocial paradigm in order to transcend the single-cause health-disease process and affirm the relevance of health care focused on prevention and promotion with a multidisciplinary team aimed at promoting continuous, safe and comprehensive care.⁽²²⁾

Researches^{(5,6,13,16,18)} indicate the growth and incentive of postgraduate courses as an influence for APN, because nurses have a greater theoretical-practical qualification.⁽⁴⁾

This fact corroborates the period of dissemination of APN throughout the world, and the graduation of the first master’s classes in Latin America and the Caribbean, first in Venezuela and Colombia, and in the following decade in Brazil.^{(6,7,9,13,20,21)}

Although stricto sensu (master’s) courses are recent in Latin American countries, their number has increased significantly, especially in countries such as Brazil, where there were about 52 master’s and doctoral courses in 2014. This fact indicates growth and dissemination of research.^{(5,6,9,13,16,23)}

APN legislations in Latin America and the Caribbean

The inclusion of the APN is not a uniform reality in Latin American countries. Jamaica and Belize are the countries with the greater experience in trying to implement this practice, and even if limited, ANP certification programs have been issued since 1992 with government support from local health reforms, and because of human resources shortages in underserved areas.^(5,6)

On the other hand, the difficulties or not for implementation of ANP in Latin America and the Caribbean change according to the demand, and cultural, social and economic aspects of each region. Countries such as Brazil, Mexico, Chile and Colombia are the most susceptible to APN and more prepared to put it into practice, given their increasing number of undergraduate and postgraduate courses.^{(5,6,8,9,13,17,20)}

In Brazil, both master’s and doctorate courses have two versions, academic and professional, which contributes to the adaptation of educational programs for the promotion of APN.^(5,13,17,18) Mexico and Chile have partnerships with US university centers for implementation of APN, while in Colombia, the nursing and politicians participate in the preparation of the context.^(5,16)

However, regulations and legislations of the various countries are not favorable to APN given the lack of knowledge about the importance and benefits that it can generate for health services and/or by considering the existence of such workers in the field of local health care as unviable and unnecessary.^{(5,8,9,13,17,19,20)}

However, among Latin American countries, Brazil is the most likely to implement APN. The country has already established a foundation focused on the autonomy and relevance of nursing in the health setting, and an example is the Law of Professional Exercise and National Policy of Basic Care (Portuguese acronym: PNAB).^(24,25)

A study⁽⁶⁾ conducted in Latin American and Caribbean countries demonstrated that 88% of participants are unaware of regional regulations on APN and the prospects for their development. However, in pilot projects in Brazil⁽¹⁸⁾ and Chile⁽¹⁶⁾, the aims are to provide training for NP in pediatric oncology and in PHC, respectively.

Therefore, it is essential to advance nursing education regarding the standardization and effective participation of trained teachers with specific skills for APN^(5,13,19) and in movements that instigate the reflection of managers and governments on advances of this practice and thus institute policies for encouraging APN.^(6,8,9,17)

Conclusion

Among factors of the contexts analyzed, APN in Latin America and the Caribbean has the potential to be implemented because of organizational and educational movements to optimize the nurses’ skills given the population need for access and quality of health services. Advances in APN are a highlight of its strengthening in Latin America and the Caribbean, as well as satisfactory prospects for the promotion of APN in rural areas and those of difficult access in order to promote greater health care coverage. However, there are barriers to the establishment of APN, the other health team professionals’ resistance to APN nurses, the lack of investment and disinterest of the government and public agencies, and the lack of favoring legislations for strengthening the practice. The low number of studies found did not allow establishing further generalizations, which may not have contributed to the achievement of new propositions. It is imperative to promote discussions with political and educational organizations interested in implementing APN; to publicize the successful experiences of this practice in health services in order to provide accessibility and continuity of care to the local population; and strengthen the relevance of nursing in health services.

Acknowledgements

Thanks to the Conselho Nacional de Ciência e Tecnologia (CNPq; Research Productivity 2 scholarship) and to the Coordenação para o Aperfeiçoamento de Pessoal de Nível Superior (CAPES; master’s scholarship).

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Publication Dates

• Publication in this collection
  Nov-Dec 2018

History

• Received
  3 Sept 2018
• Accepted
  29 Oct 2018