The euphemism of good practice or advanced nursing practice

El eufemismo de las buenas prácticas o la práctica avanzada de enfermería

ABSTRACT

Objective:

To analyze how the focus given nowadays in our country to good practices in the care process as centrality of Nursing offers support to the discussion about the expansion of nurses' performance through advanced practices.

Method:

This is a theoretical-reflexive article, based on critical reading of studies on the subject, focused on the need to discuss the training of nurses in the perspective of their role expansion.

Results:

The arguments for both subjects, based on the discussion of the theoretical reference of the two themes: good practices or practice based on evidences, and advanced practice nursing.

Final considerations and implications for practice:

It is proposed that, in addition to good practices, undoubtedly necessary, the appropriation of advanced nursing practice and the debate about its adoption in the country are fundamental to the new professional challenges facing nursing and the training of human resources for the Unified Health System. The arguments presented lead to the knowledge of the nursing topic of recent dissemination in Brazil, the advanced nursing practice, which can substantially change the nurses' performance in our reality.

Keywords:
Nursing professionals; Nursing process; Nurse's role; Advanced Nursing Practice; Evidence-based nursing

RESUMEN

Objetivo:

Analizar cómo el enfoque dado actualmente en el país a las buenas prácticas en el proceso de cuidado como centralidad de la enfermería ofrece suporte a las discusiones sobre la expansión de la actuación del enfermero por medio de prácticas avanzadas.

Método:

Artículo teórico-reflexivo, construido con base en la lectura crítica de estudios sobre la temática, centrándose en la necesidad de discutir la formación del enfermero en la perspectiva de la expansión de su actuación.

Resultados:

Los argumentos para ambos asuntos son fundamentados en la discusión del referencial teórico de los dos temas: buenas prácticas o prácticas basadas en evidencia; y enfermería de práctica avanzada.

Consideraciones finales e implicaciones para la práctica:

Se propone que, además de buenas prácticas, sin duda necesarias, la apropiación de la enfermería de práctica avanzada y el debate sobre su adopción en el país son fundamentales para los nuevos desafíos profesionales que se colocan a la enfermería y para la formación de recursos humanos para el sistema único de salud. Los argumentos presentados conducen al conocimiento de la enfermería tema de reciente difusión en Brasil, la enfermería de práctica avanzada, que puede cambiar sustancialmente la actuación del enfermero en nuestra realidad.

Palabras claves:
Profesionales de enfermería; Proceso de Enfermería; Papel de la enfermera; Enfermería de practica avanzada; Enfermería basada en la evidencia

RESUMO

Objetivo:

Analisar como o enfoque dado atualmente no país às boas práticas no processo de cuidado como centralidade da enfermagem oferece suporte às discussões sobre expansão da atuação do enfermeiro por meio de práticas avançadas.

Método:

Artigo teórico-reflexivo, construído com base na leitura crítica de estudos sobre a temática, voltado à necessidade de discutir a formação do enfermeiro na perspectiva de expansão da sua atuação.

Resultados:

Os argumentos para ambos os assuntos são fundamentados na discussão do referencial teórico dos dois temas: boas práticas ou práticas baseadas em evidência; e enfermagem prática avançada.

Considerações finais e implicações para a prática:

Propõe-se que, para além de boas práticas, sem dúvida necessárias, a apropriação da enfermagem prática avançada e o debate sobre sua adoção no país são fundamentais para os novos desafios profissionais que se colocam à enfermagem e para a formação de recursos humanos para o sistema único de saúde. Os argumentos apresentados levam ao conhecimento da enfermagem tema de recente veiculação no Brasil, a prática avançada de enfermagem, que pode mudar substancialmente a atuação do enfermeiro em nossa realidade.

Palavras-chave:
Profissionais de enfermagem; Processo de enfermagem; Papel do profissional de enfermagem; Prática avançada de enfermagem; Enfermagem baseada em evidências

INTRODUCTION

This article of reflection is necessary at this moment, addressing two complementary themes for the nursing work in our country, which concern both the training for the job and the expansion of the professional's attributions, mainly because studies demonstrate their potential to improve the quality and effectiveness of health systems^1-2, and specifically of primary health care, namely: the use of evidence guiding practice and the Advanced Nursing Practice (ANP).

To introduce the term ANP, one can assume that it is broad and includes a variety of functions. In addition, it is also used as a title for the Advanced Practice Nurse (APN) in some countries. Thus, different definitions of this practice exist worldwide, with a variety of nomenclatures, generating confusion between function, use of the term, academic titles, and training.³ Despite this confusion, the term ANP will be used in this text to address the general function and APN by specifically mentioning the professional.

As in our reality the ANP is not formally recognized, neither by legislation nor by professional training, according to the definitions given internationally to this practice, it is necessary to approach the subject, since some of these actions are adopted in the daily work, such as the prescription of medicines⁴ from primary care protocols.⁵

The adoption of clinical evidence to guide practice based on protocols and guidelines, as well as the expansion of functions, even if not widely regulated in the country, brought both prominence and difficulties to nurses, especially in primary care.⁵ The prominence results from the increase in the autonomy derived from the daily routine of nurses.⁶

On the contrary, the difficulties which nursing currently faces in primary care in Brazil nowadays range from the lack of professional training for the application of complex skills and changes in basic health care legislation, to the recent attempts of two different professional councils, one to prevent the practice of requesting examinations and prescription of medicines by nurses⁷, regardless of whether they are guided by basic care protocols, and another to place under their auspices two practices that take part of the nursing core activities, the care of wounds and burns.⁸

At the same time, the Federal Nursing Council, aiming to qualify about 500 professionals over a four years period, supports research through professional masters, in partnership with the Coordination for the Improvement of Higher Education Personnel, aimed at the systematization of nursing care since 2016⁹, there are other professional councils investing against nursing actions, or with the intention of curbing the work and the advancing of the functions, or formally appropriating these through court judgments, designating those functions historically developed by the nurse.

The Medical Council presents on its online page: "nurses cannot perform consultations in which they offer the patient a diagnosis of diseases and the prescription of exams and medications, as well as referral to other professionals or services"⁷. Based on this understanding, the same council filed a lawsuit in the Federal Court to suspend the effects of Ordinance No. 2488/2011, of the Ministry of Health, which defined the National Basic Attention Policy (NBAP), modified in 2017 and in force since then, through order No. 2436/2017-MS¹⁰, but which retained the prerogatives to which the medical council had manifested itself against. Thus, it obtained an injunction in court that prevented, during a certain time, the free exercise of the activities mentioned, by the nurse, in the year of 2017. The Medical Council expressed on the subject, on its online page, the following statement: "the decision, considered an important victory of the Brazilian doctors in defense of the exclusivity of the activities foreseen in Law No. 12,842/2013 (Law of the Medical Act), attends to the lawsuit filed by the Federal Medical Council"⁷.

However, since this was a preliminary decision, when it was replaced by the definitive decision, it reinstated the provisions of the NBAP. The request for revocation, made by Brazil's General Advocacy against the 20th Federal Court of Brasília, whose decision of the Regional Federal Court of the First Region (RFC-1) cannot be appealed, ordered the dismissal of the case because it represented "interference by the Judiciary in the implementation of the public policy of Basic Attention of the Unified Health System", generating "serious damage to the public-administrative order and to public health"¹¹.

In addition, the practices, which were imputed as improper and here reported as being part of the ANP, have already been a legal provision of the profession since the publication of the law of professional practice No. 7,498/8612, which establishes, in its article 11, that the nurse performs all the nursing activities, being assigned, privately: nursing consultation; nursing care of greater technical complexity and requiring scientifically based knowledge and the ability to take immediate decisions; and as part of the health team: prescription of medications established in public health programs and in a routine approved by the health institution.

Recently, court decision 924/2018 of the Federal Council of Physiotherapy and Occupational Therapy⁸, extended to physiotherapist the qualification to treat wounds and burns. Federal Nursing Council¹³, in turn, filed the lawsuit 1029118-91.2018.4.01.3400 highlighting the absence of legal basis for the physiotherapist's performance in the treatment of wounds and the inexistence of training of these professionals for this practice.

This is the current professional paradox, since, while discussing the adoption of the ANP, which foresees the performance of functions that previously did not integrate the duties of the nurse, other professionals, perceiving gaps of performance, seek to assume to their role of attributions, practices before exclusive to nursing.

It is brought as a counterpoint, the evolution of nursing as a science and profession, since its concrete progress is undeniable in all fields and, more specifically, through the Post-Graduate Programs. Since the first Masters Course at the Anna Nery Nursing School, in 1972, taking into account the development policy in the country, until 2016 in the last evaluation from the Coordination for the Improvement of Higher Education Personnel, there was an significant growth, reaching in 2017 the numbers of 96 Post-Graduate Programs and 49 Academic Masters, 34 PhDs and 19 Professional Masters - PM (the first one was created in 2002 at the Universidade Federal Fluminense).¹⁴ In this group, the PM stand out, which have expanded strongly in recent years, with a relative growth of 156%, "representing 20.5% of the approved courses of the Nursing Area in December 2016, attending to the training of professionals for the health services in compliance with the National Postdoctoral Program (NPDP) 2011-2020 and consolidation of the Unified Health System"¹⁵.

In the conquest for its space, the profession sought to establish itself as a science, by developing investigations that subsidized its practice through a body of own knowledge that also sought interlocution with other areas of knowledge. At this juncture, we have witnessed an increase in evidence-based research, the discussion about ANP and the substantial growth of clinical studies and the number of professionals with masters, doctorate and postdoctoral degrees.

Given this evidence, one must ask: do good practices and/or evidence-based practices in the care process as a centrality of nursing support the adoption of the APN?

OBJECTIVE

To analyze how the current focus in the country on good practices in the care process as the centrality of nursing offers support to the discussions about the expansion of nurses' performance through advanced practices.

Good practices in the care process

It begins with the theme of good practices and/or evidence-based practice, coming from an appropriate training for professional practice and constantly guiding the practice through care protocols or guidelines. Since 2002, with the change in the national curricular guidelines for the undergraduate course, the aim is to train the generalist nurse, able to act competently in all spheres of care. Has the objective, in fact, been achieved? The time and experience accumulated in those fifteen years, since the reformulation of graduate schools, have shown that there are weaknesses to be overcomed.¹⁶

However, before beginning this argument, a conceptual clarification about good nursing practices and evidence-based practice is needed. In this way, it is worth discussing both through their concepts and differentiations.

Good practice consists essentially of a triad that encompasses the best results of scientific research, clinical expertise and the needs of each patient/individual. Thus, the nursing professional relies on the best evidence for clinical management, updated periodically.^17,18 These good practices work in specific situations and contexts, such as primary care protocols, usually by optimizing the use of resources in order to achieve the desired results. Good practices add elements that contribute to the success of interventions.¹⁹ Research is part of a major strength of the nursing profession and is used as a tool to change practice, education, and health policies.

The Evidence-Based Practice (EBP) aims to encourage the use of research results in improving health care at different levels of care, reinforcing the importance of research for clinical practice.²⁰ The EBP has the potential of qualifying work in health as a strategy for clinical effectiveness and produces bases for decision making, where the professional performs the care. It is based on the identification of a problem and decision making anchored in the knowledge already produced on the subject, adding to the knowledge acquired in practice. This practice constitutes a permanent field of knowledge, and which is constantly improving and constructing to produce analysis and greater understanding of health phenomena.^21,22

We believe that starting the discussion about training seems pertinent, since, at the same time that competence education was defined, it allowed for a more flexible interpretation of the guidelines, previously non-existent in our reality. What flexibility are we talking about? Of the interpretation of practical teaching, since theoretical and practical subjects, in a course with predominantly technical training, started to be performed with reduced hours of practice, corresponding to 20% of the total hours that should be part of the curricular stage, as the essential principle developed in the graduation school throughout the country.²³

In recent e-MEC survey on the distribution of undergraduate nursing courses in the country, the concentration of courses in the Southeast, Northeast and South regions is maintained, and a predominance of training, with over 90% in private institutions, is perceived.²⁴ This teaching has been characterized by the precariousness of practical activities in the training of nurses. Thus, there was an increase in the number of vacancies, although below the expected minimum level, without the necessary expansion of the training quality.²⁵

Another aspect concerns the organization of nursing work in Brazil. Far from the reality of the developed countries, in which only the nurse in his/her different specialties is practicing the profession, as in the United Kingdom, Spain, Portugal and the United States of America, we have in Brazil the division of labor into three categories or more. In contrast to those countries that have made the option of single occupations since the 1980s, forming a bachelor's degree nurse, in Brazil the profession has always been divided into several levels, and is currently composed of the nursing assistant, the nursing technician and the nurse. More recently, in primary care, with the entry of community health agents under the supervision of nursing was added another occupation not formally regulated in the nursing team (Law 7498/1986) neither came from the aspirations of the profession. In addition, according to the latest version of the NBAP, it also began to take on technical care that was beyond its competence, such as checking blood pressure, performing dressings and examining blood glucose levels.^10,12

In addition to the division of labor and the precariousness of nurses' training, there is a precariousness in employment relationships; the overload of activities; the difficulty in carrying out complex actions in primary care, despite the density of actions in this level of care in the health sector; regional disparities, which greatly influence daily work in the country.²⁶

Thus, thinking about strategies of good care practices is fundamental, because when we recognize training with a quality deficit, it becomes necessary to adopt strategies that help and enable the daily work. This discussion pervades the inclusion of permanent education as a support mechanism for professionals, along with refresher courses and training in educational institutions, complemented by the use of care protocols in all spheres of attention, through evidence-based nursing practice, only to mention the most usual ones.

In the health sector, there has been flexibilizing of the working conditions before the recent change in national legislation on the subject. Examples of such precariousness are the contracts based on bidding, outsourced employment contracts through foundations and Civil Society Organizations of Public Interest (CSOPI), the working relationship as a service provider and other modalities, both in the public and private sectors. From this precariousness of the work, a fragility is perceived in the relationship and conditions for the professional exercise, as well as for the execution of good practices.²⁶

In addition, the profession needs to reflect on its social division at work. To whom interests nursing divided into subcategories? Why not invest in the training of all professionals at the undergraduate level, such as nurses? In this sense, there could be those who, from a general education, would dedicate themselves to primary or hospital care, subsequently acquiring the necessary expertise, through complementary training, to carry out specific activities in a single professional category.

Investing in this training takes time, but it is possible, if it is an objective of the profession. For the time being, what exists is a differentiated formation in public and private schools that neither serve the interests of the profession nor the formation of human resources for the Unified Health System (UHS).^27-28 So discussing good practices for care is necessary, since the performance is very different in the country. Adopting the axis of systematization, besides being important, is a guide to the differentiated, quality and private practice. But, beyond that, using evidence-based practice, integrated care protocols, in a digital form, with training for its use, as in developed countries, qualifies health care in all spheres of care, being pertinent that it is in the centrality of the discussions of the nursing in the country and that the adoption of this practice is extended.

About the Advanced Nursing Practice (ANP)

Starting in 2014, after initiating studies on the subject of the expansion of nursing practice²⁹ and investigating the reality of their work in primary care in England, and later, covering studies of other realities, the autonomy for the work that these professionals hold in the sphere of primary care was perceived. This autonomy stems from the quality of training, from the technical-scientific competence to the exercise of their professional activity, but also from the formal support of the national health system in the realities in which it is adopted.^1,2

Studies show that ANP originated from the 1950s in the United States, initially in the hospital setting, with the Clinical Nurse Specialist (CNS) and then, in 1960, in primary care with Advanced Practice Nurses (APN) or Nurse Practitioner (NP).^30-32 The advent and expansion of ANP over time was related to increased accessibility and coverage in primary care, maintaining the quality of care. In Canada, it began in the late 1960s, and in Europe and Asia in the 1980s.^30,31,33 In Latin America, ANP is still incipient and only now, in the 21st century, through the promotion of the Pan American Health Organization (PAHO) and of researches carried out in educational institutions, its existence has become a possibility.^29,34,35

In some of these realities, such as the United Kingdom, what determines whether a professional will be or not an evaluator/case manager, if he/she will be diagnosing and will be a prescriber of medications, are the guidelines established by the National Health System, not only for the ANP, but for all the professions with these prerogatives²⁹, and not the professional councils, as in the case of Medicine and Dentistry in Brazil. However, for this register as a prescriber to occur in the National Health System, it is necessary to acquire capacity for clinical reasoning and the conduct of therapy. For this, the nurse needs to obtain advanced practice training, preferably by master's or doctorate degree, but also with complementary training, in specific courses for the management of specific clinical situations, usually of the predominant chronic conditions in the United Kingdom.²⁹

When initiating the discussion of ANP insertion in Brazil, which interferes not only with the professional practice of the nurse, but also with other professions, caution is advised. Especially when they manifest themselves threatened, as in the case of the Medical Council, cited previously, which went to Court to prevent what it understood as an extension of the practice of nurses. Similarly, the Nursing Council adopted a similar posture when Physiotherapy requested activities from the nurses' field of action.

A similar situation occurred in the past when the Ministry of Health attempted to implement the first advanced practice protocol - it was not yet discussed, at least with this name - in the early 2000s. With the support and encouragement of the PAHO, the Integrated Management of Childhood Illness (IMCI),³⁶ adopted by the Brazilian Ministry of Health, had no progress in Brazil, given the possibility of the nurse performing diagnoses and prescribing medication, following the protocols for child care. The attempt to adopt this protocol widely in the country led to the beginning of the discussions for the creation of the Law of the Medical Act.

These initial difficulties marked the development of ANP in countries where it has been carried out for a long time. However, the success of its implementation was linked to the absence of care in distant places and in which other professionals, such as the doctor, did not remain. At the same time that it made possible the expansion of access to those who previously did not receive any health care, it also overloaded the profession with activities previously carried out by doctors.¹

Let us see, therefore, how the APN is defined, according to the International Council of Nurses (ICN): "the 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 he/she is credentialed to practice. A master's degree is recommended for entry level".³⁷

This practice has been disseminated in our reality, mainly by PAHO, whose nursing representation has been establishing joint strategies with the Brazilian Nursing Council ("COFEN") and the Brazilian Nursing Association ("ABEn") to discuss ANP, in order to reflect on the increase in the scope of practices in the country. The PAHO has recently published the publication "Expanding the Roles of Nurses in Primary Health Care"³⁸, bringing to light the discussion of its implementation in the Americas region.

According to this document, at the time of the 68^th World Health Assembly, in 2015, the need to strategically and substantially invest in human resources for health was acknowledged, since public systems are neither training nor acquiring the necessary number of professionals, especially in primary health care.³⁸

The most recent studies in the countries that have adopted it show that ANP has as much or more competence than the doctor in monitoring chronic conditions in primary care, for example, noting that a practice which started in order to take care to places where before there was none, proved to be efficient and less costly for the government, since the salary of the nurse historically is lower than that of the doctor.^1,2,33,39

In order to discuss the adoption of the APN in the country, it is necessary to fundament it. First, the recommendation is that this professional has a master's³⁷ or a doctorate degree. Also, work in a specialty of nursing care practice that provides direct patient care, including evaluation, diagnosis, care plan, and prescription of medications. However, it should be noted that the APN works from a training, a field of expertise, both for the care of a health problem, and also for the promotion and prevention. Their main attributions include: collaboration and leadership, research, guidance and follow-up of other nursing professionals, ethical judgment and clinical competence.⁴⁰

In order to increase the density of human resources in health, countries have initiated strategies, such as the "Mais Médicos" Program in Brazil, to minimize the problem of the lack of doctors in distant places and to improve the actions of primary health care and family health in places where access to these professionals is limited.⁴¹ However, only the increase of the number of doctors has not been enough to solve the problem of expanding access and resolution in primary care, so it is necessary to discuss the expansion of the attributions of other professionals, specifically of the nurse.

In the case of the United Kingdom, which has adopted the ANP for over 50 years, there is still resistance to this function being widely disseminated. As a result, the United Kingdom participates in the global campaign called Nursing Now, which began in 2018 with a focus on the need of, without delay, promoting actions to put the nurse in the spotlight, highlighting him as an important professional, which can contribute to the health problems of the population if able to develop his full potential. Its main recommendations are: to make nursing the central axis of health policies; to support the increase in the number of nurses around the world; to encourage nursing leadership; to encourage nurses to develop their full potential; to provide evidence of the positive impact of nursing, both on access and on quality and impact on health costs; to encourage nursing to be incorporated into health policies; to consider the threefold impact of nursing in the design and implementation of policies: "on health, on gender equality and on economy".^38:5

For the countries of Latin America, the PAHO document³⁸ proposes the APN with three main specificities: a) Nurse practitioners - nurses with master's degrees, in order to serve the users of primary care in the management of acute and chronic acute diseases; b) Nurse case manager - with the objective of working in integrated networks of the health system as an element of connection and integration between levels of care, during patient care; c) APN specialist in obstetrics - for the care of pregnant women.

In addition to these proposals, the PAHO³⁸ discusses the essential competences of the APN, considering the International Council of Nurses (ICN), and summarized below: a) clinical practice: competence to be a consultant, collaborator, communicator, to have critical thinking, advanced skills to evaluate, to intervene, analyze, make ethical decisions and lead. b) training: to educate, guide and be a model of behavior and performance. c) research: to improve the quality of care and its practice, through evidence from the literature. d) professional and organizational development: to be an agent of change and lead, to generate governance systems, to implement evidence-based protocols, to optimize processes and policies, among other activities.

In order to contribute to these premises, there is a discussion about training for ANP in Brazil, demonstrating the potential of nursing residencies, with its over five thousand hours and also professional master's degrees, a topic that needs further study and can be encouraged from the involvement of the class institutions, of the category's regulation council, as well as the Ministries of Health and Education, which are the major stakeholders in the training of human resources for the UHS.⁴²

In line with the PAHO's proposal, also in 2018, the "COFEN" decided to invest in national research, under the coordination of the University of Brasilia, to diagnose the reality of ANP in the country under the name "Nursing Practices in the Context of Primary Health Care (PHC): National Study of Mixed Methods", from which a broad picture of reality is expected, both from the performing of good practices and from advanced practice experiences, if they occur.

This research intends to play a fundamental role in the diagnosis of nursing practice in primary care in the country, since the tendency of this professional has been to consider that it already develops the ANP, in a discourse in which "doing everything"⁴³ prevails. However, as previously discussed, this professional does not have the training nor the competence nor the legal/formal support for it, neither the recognition of society that it develops this practice, with the meaning that it assumes in the countries where it is adopted.

CONCLUSION

In summary, it is necessary to integrate the knowledge obtained through good practices and evidence-based practice to advance in the discussion about the implementation of the ANP in Brazil. Since the responsibility for regulating the professional role can be shared between the ministries of Health, Education and other government agencies, in addition to professional councils, a meaningful dialogue must be established.

Going back to the objective of this reflection, to discuss the centrality of good practices and their potential to contribute to the ANP, we think that both complement and support the dialogue on the topic. The implementation of the ANP should take into account the identification of health needs of the population and the expectations of nurses regarding their professional and social roles, as well as strengthening their inclusion in the curricular discussions and the research developed, related to the social and political reality of the country.

In addition, regulating the role of the APN is the foundation that will sustain the practice coupled with the quality of training for these future professionals. Thus, professional councils and government agencies, as well as the professionals themselves, must agree on the process of regulation, training and scope, without the conflicts that may arise from a practice not recognized as such, by all the subjects involved.

Nursing care can bring about, from the knowledge of nursing to new ways of dealing with human diversity and the responsiveness of individuals and communities, in different ways of operating healthcare. The ANP can converge so that the guiding principles and concepts of the Unified Health System are fulfilled in health practices, especially in primary health care. Of course there is a long way to go in this direction.

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Publication Dates

• Publication in this collection
  04 July 2019
• Date of issue
  2019

History

• Received
  26 Dec 2018
• Accepted
  07 May 2019