Women’s Health Care in Advanced Practice Nursing: a professional master’s degree program

Abstract

The Professional Master’s Program Women’s Health in Advanced Practice Nursing has integrated the concepts of advanced practice nursing into a professional master’s education. Advanced practice nurses develop further clinical and research competencies than traditional nurses, and their roles include continuous improvement of health care outcomes, inclusion of more individuals in the health care system, and expansion the limits for their practice. Advanced practice nurses play a role on promote innovative measures, create and implement protocols, institutional care processes, and public policies. The program focus on the following three areas: 1) To increase obstetric nurse and midwife’s decision-making autonomy in antenatal, natal, and postnatal settings, mainly in the context of home birth and birthing centers; 2) To promote care competencies and creation of policies that cover violence against women; and 3) To propose a transformative practice on women’s mental and reproductive health, sexual orientation, and gender identity. This innovative Program is aligned with the movement towards the introduction of Advanced Practice Nursing in Latin America.

Advanced practice nursing; Women’s health; Education, nursing; Health human resource training; Education, nursing, graduate

Resumo

O Mestrado Profissional em Prática Avançada na Saúde da Mulher integrou os conceitos de Enfermagem em Prática Avançada ao Mestrado Profissional. As Enfermeiras de Prática Avançada desenvolvem competências clínicas e de pesquisa superiores às tradicionais e desempenham papéis visando a melhoria contínua de resultados em saúde, a inclusão de mais pessoas no sistema de saúde e a expansão dos limites da prática. As Enfermeiras de Prática Avançada atuam na inovação, na construção e na implementação de protocolos, de processos de cuidado institucionais e de políticas públicas. Três focos compõem o programa: 1) Aumentar a autonomia da enfermeira obstetra para a tomada de decisão no pré-natal, no parto e no pós-parto, especialmente em domicílio, casas e centros de parto; 2) Impulsionar a competência para o cuidado e a construção de políticas sobre violência contra a mulher; e 3) Propor uma atuação transformadora sobre a saúde mental e reprodutiva da mulher, opção sexual e de gênero. Trata-se de programa inovador que se alinha ao movimento para a introdução da Enfermagem Prática Avançada na América Latina.

Prática avançada de enfermagem; Saúde da mulher; Educação em enfermagem; Capacitação de recursos humanos em saúde; Educação de pós-graduação em enfermagem

Resumen

La Maestría Profesional en Práctica Avanzada en Salud de la Mujer integró los conceptos de Enfermería de Práctica Avanzada a la Maestría Profesional. Las Enfermeras de Práctica Avanzada desarrollan competencias clínicas y de investigación superiores a las tradicionales y desempeñan papeles que buscan la mejora continua de resultados en salud, la inclusión de más personas en el sistema de salud y la expansión de los límites de la práctica. Las Enfermeras de Práctica Avanzada actúan en la innovación, en la elaboración y en la implementación de protocolos, de procesos de cuidado institucionales y de políticas públicas. El programa tiene tres focos: 1) aumentar la autonomía de la enfermera obstetra para la toma de decisiones en la atención prenatal, en el parto y en el posparto, especialmente en atención domiciliaria, casas y centros de parto; 2) impulsar la competencia para el cuidado y la elaboración de políticas sobre violencia contra la mujer; y 3) proponer una actuación transformadora sobre la salud mental y reproductiva de la mujer, opción sexual y de género. Se trata de un programa innovador, que está en línea con el movimiento para la introducción de la Enfermería de Práctica Avanzada en América Latina.

Enfermería de práctica avanzada; Salud de la mujer; Educación en enfermería; Capacitación de recursos humanos en salud; Educación de postgrado en enfermería

Introduction

Worldwide nursing is recognized as the backbone of the health care system. However, little is known in Brazil and in most developing countries about actions to promote nurses’ autonomy, and to have them proposing transformative policies and actions, developing creative and technological solutions that can positively change health care outcomes, and taking on research roles to solve challenges of advanced care. Professionals with these competences are found in developed countries and they have contributed to changes in science, health care outcomes, and nursing. The lack of these professionals means a disadvantage to our health care system.

A study funded by the UK’s All Party-Parliamentary Group on Global Health (APPG) aiming to improve overall health care showed that empowering nurses through strengthening and widening their set of competencies can improve health care, promote gender equality, and help economic growth. The APPG’s Triple Impact of Nursing 2016 report states that universal health cannot be reached without strengthening the role of nurses. Such conclusions and recommendations were forwarded to the United Kingdom, European Union, and the World Health Organization (WHO) authorities. They received them so well that it was decided to launch a new global campaign, called Nursing Now in a partnership with the WHO and the International Council of Nursing (ICN). Nursing Now is a 3-year campaign (2018-2020) for the global improvement of health by raising the status and profile of nursing. The campaign has gained support all over the world, and many countries have invested in nursing, the year of 2020 was designated as the Year of the Nurse and the Midwife.(¹)

In Brazil, nursing education and training include: undergraduate programs, specialized programs (360 hours), residency programs (5,760 hours), self/continuing education by participation in short courses, conferences, and also independent studies, and academic and professional graduate programs (Master’s degree and PhD program). Of note is that the number of professional graduate programs in the field is limited. Academic master’s degree and PhD programs, which are well established in Brazil, focus on development of professors and researchers, while professional graduate program, such as the professional master’s degree aims to help professionals to improve their practice by adopting and undertaking reflexive, critical, and transformative approaches.(²)

This variety of educational paths to acquire competencies has certainly allowed the training of a considerable number of Brazilian nurses, but this variety also turns education potentially slow, inefficient, and restricted. This type of education does not contribute to the development of nursing and health care with the speed and consistency needed compared with well-structured programs that aim to provide highly qualified health care providers who may transform and improve health care setting.

Advanced-practice-oriented education was established in the 1980’s in developed countries, including but not limited to Canada, the USA, England, and Australia, under the title of Advanced Practice Nurse (APN), and this has been shown to be effective in including health care providers with specific and differentiated competencies in the health care systems, and consequently improve health care and health care indicators. In Brazil, there are opportunities to implement this advanced education as well as a number of working areas for the APN. However, the country lacks standardized education for APN (e.g., advanced clinical competencies, outstanding research, and leadership competencies), in addition, professional roles for qualified professionals are often not well-established, as well as proper payment or titles that adequately identify them.(³)

APNs possess the skills and clinical competencies to make complex decisions, expand and improve nursing practice, promote inclusion, and provide better evidence-based care and technological innovations. A master’s degree is the minimum educational level required.(⁴)

The APN’s title denotes a level of practice rather than a type of practice. Nurses at this level holds a master’s degree and have highly specialized knowledge and expert clinical practice, and they are recognized for that, for this reason, they have authority to act and make autonomous decisions regarding assessments, diagnoses, and treatments.(⁵)

The Pan American Health Organization (PAHO) and the WHO launched the publication “Expanding the Roles of Nurses in Primary Health Care”,(³) in this document authorities and nurses from countries of the Americas are invited to implement APN education for primary health care and midwives. The report also highlights the potential of nurses from Central and South America who have already available undergraduate, residency, master’s degree, and PhD programs. The goal is to provide better coverage and health care for users, in addition to leveraging our nurses’ intellectual capacity and retaining good providers in the profession. For PAHO, new professional profile such as the APN, in addition to contribute to promote health, prevent diseases, and reduce deaths, can assume more autonomous roles in primary care services in vulnerable areas, within cities, and in remote areas.(³)

An editorial published in Lancet, in the international year of nurse (2020), highlights the importance of the profession that accounts for nearly half of the global health workforce, approximately 20 million nurses and 2 million midwives: “Working in a wide variety of roles and in many different contexts, nurses are often the first and the only health professional who people have close contact.” The editorial defends the expansion of nurse clinics as a way to allow “rapid and cost-effective expansion of services for non-communicable diseases, advanced practice nursing and specialized nurse who could strengthen primary care”, among other sectors.(⁶)

Brazil’s Federal Council of Nursing (COFEN) supports this APN initiative. COFEN has set up a commission to assess the implementation of advanced practice nurse in Brazil and also has been funding professional master’s degree programs. COFEN considers that nurses educated in advanced practices are paramount to health promotion and disease prevention.(⁷)

The educational requirements of the advanced practice nurse are perfectly aligned with professional master’s degree program that aims education of health care providers who would be able to promote innovative approaches to the job market, and has the following goals:

I - Train a qualified workforce to perform advanced professional practice and transform procedures, with the goal of fulfil social, organizational, or professional demands of the job market; II - Transfer knowledge to the society, fulfil specific demands and produce demands for local, regional, or national development; III - Promote an integrative professional education with diverse institutions requiring this education with the goal of improving efficacy and efficiency in public and private organization through problem-solving and the application of adequate innovation processes; IV - Contribute to the competitive job market and increase productivity at private companies, public and private organizations.(⁸)

The professional master’s degree is a complete program for health care providers who seek to develop basic research competencies, learn how to deal with scientific research, find meaningful studies, in addition to learn how to apply theory in the work environment, measure results, develop and implement innovations. All these require that student learn to develop advanced competencies for the job market. Competencies to be learnt in the professional master’s degree program are diverse, and with the same level of complexity of those from the academic master’s degree program. The aim of the professional master’s degree proposed by the Brazil’s Higher Education Improvement Coordination (CAPES) is perfectly aligned with education required for APN, this is the reason to combine these two concepts.

Given the potential to implement the APN in Brazil and also the academic recognition of the relevance of professional master’s degree as a transformative education strategy for the job market, the Nursing School of the Federal University of Sao Paulo (EPE-UNIFESP) has proposed the organization of professional master’s degree program on women’s health in advanced practice nursing (MEPASM), which the future possibility of development of other areas of studies. The objective of this paper is to present this proposal.

Methods

This proposal originated from the wish of EPE-UNIFESP to organize a professional master’s degree program for APN, from the existence of highly specialized faculty in Women’s Health, and also for the opportunity of two visiting professors with previous experience in designing graduate programs be at our university at the time. The proposal is based on published literature about APN(³,⁴,⁵,⁹-¹¹) and professional master’s degree program, CAPES guidelines, and meetings with the university board of directors, Graduate Council, the Graduate Committee, EPE’s faculty members, and EPE’s faculty members specialized in Nursing for Women’s Health. The program was peer reviewed within the institution, as well as reviewed by EPE-UNIFESP’s Graduate Council, and UNIFESP’s Dean Office, and then submitted to the CAPES. The proposal’s main subjects and disciplines were chosen based on principles of APN, epidemiological prevalence of events/injuries in the context of Women’s Health in Brazil, gaps and needs to promote a transformative care in the area.

Results

The Nursing School of UNIFESP includes faculty and researchers with proven experience with education of master’s degree and PhD students, and in research. The Nursing School academic graduate program \ offering began in 1978 with the master’s degree in pediatric nursing, followed by the master’s degree in obstetric nursing in 1980, a PhD in maternal and child health nursing in 1986, and the nursing in adult health program in 1989. Currently, our graduate department offers a master’s degree and PhD programs and a joint PhD program (DINTER) with the Federal University of Acre. EPE also offers the Professional Master’s degree in Health Science Teaching.

The EPE’s Nursing in Women’s Health Department is a traditional and national leader in terms of education of obstetric nurses since 1979 by offering specialization and residency programs. The faculty’s expertise and leadership within the community and the nursing associations support the professional master’s degree proposal in women’s health in advanced practice nursing.

Program goals and student profile

Of the analysis of epidemiological profiles, health policies and care needs in women’s health, APN principles, and PMD goals, three broad topics were chosen to constitute the guiding points of this proposal: greater autonomy of nurses in the antenatal, natal, and postnatal period; transformative practice of specialized nurse in women’s health in the violence against women; and in issues related with women’s mental and reproductive health, sexual orientation, and gender identity. These guiding principles were used to establish the following goals:

• Improving training of health care workers to provide advanced care for women in the puerperal pregnancy cycle, in the neonatal period, and violence against women, women’s sexual and reproductive health, sexual orientation, and gender identity. The goal is to promote a transformative and innovative practice considering social demands.

• Teaching health care providers systematic methods and scientific based to develop innovative and robust research studies.

• Developing the professional competencies to keep continuously informed and able to implement science and technology advancements into practice in Women’s Health; producing applied science; proposing innovation; and developing technologies to solve specific issues.

The Program aims at training a health care workforce that is skilled in APN in Women’s Health as proposed by ICN, i.e., high degree of professional autonomy and independent practice; case management skills; advanced health assessment skills; decision-making skills and diagnostic/clinical reasoning skills; recognized advanced clinical competencies; provision of consulting services to health providers; skills in planning, implementation, and evaluation of programs.

By the end of the Professional Master’s Degree program, the graduate student is expected to have acquired advanced training, show critical and reflexive knowledge based on the best available evidence in women’s health, thus promoting transformations and improvements in health and well-being indicators. They are also expected to have developed greater cognitive flexibility, creativity, and critical thinking, in addition to acquire outstanding negotiation, judgment, decision-making, and emotional intelligence skills. The Program also aims at providing students with the ability to synthesize and analyze data and use at advance level the existing technological tools for the care of women, both individually and collectively.

Program characterization: area of focus, lines of research, and courses

The MEPASM Program was designed to be one of EPE-UNIFESP’s Professional Master’s Degree in Advanced Practice Nursing Programs specifically covering Women’s Health (the area of focus). It will consist of three guiding principles, eleven courses, and three lines of research orchestrated around the guiding principles and courses.

The area of focus of the program, Women’s Health, was structured to prepare nurses to fulfill their roles with autonomy considering the principles of APN, evidence-based practice, and integrated women’s health. This structure is also based on Brazil’s Nursing Codes of Ethics and Deontology, principles from Brazil’s Ministry of Health, the WHO, and PAHO guidelines, and also to enable nurses to produce innovative knowledge to solve problems and improve women’s health and well-being indicators.

The three guiding principles will act as a framework to enable the program’s goals, competencies, research lines, and projects. They comprise the following 11 courses, described below.

The guiding principle of advanced care for women in the puerperal pregnancy cycle and neonatal period with an emphasis on autonomy of the nurse consists of four courses. The courses will focus on the innovative development of specialized knowledge, high-performance clinical skills, intellectual autonomy, and an investigative up-to-date critical posture for the care of women in the puerperal pregnancy cycle facing common problems or prevalent exacerbating factors (high-risk pregnancies) in primary, hospital, or outpatient care.

Courses will also discuss in depth about women’s and newborn health public policies, focusing on nurses’ autonomy. Disciplines will be: physiological and pathological bases for advanced practice nursing in antenatal, natal, and postnatal period; Brazil’s Ministry of Health, PAHO, and the WHO women’s and newborn health policies and guidelines for pregnancy, childbirth, and the puerperium; Advanced nursing in the setting of home deliveries and birth centers (theorical and practical); ICN and International Confederation of Midwives (ICM) guidelines for advanced practice obstetric nursing: legal aspects, job market, and training.

The guiding principles of advanced care in women’s sexual and reproductive health and prevention and care in the context of domestic and sexual violence consists of four courses. The courses will focus on Brazil’s Ministry of Health, PAHO, and the WHO women’s health policies and guidelines for sexuality, gender, and violence against women. Their aim will be to critically and thoughtfully discuss the APN’s practice in the context of women’s sexual and reproductive health, conception decision-making, sexual and domestic violence against women, and gender identity. We consider these to be widespread and interlinked issues. Considering these issues, advanced practice nurses must perform in a reflexive, creative, and transformative way, and promote women’s physical and mental health, as well as in a way that protects women’s dignity, safety, quality of life, and the potential workforce represented by these women.

Disciplines will be: Brazil’s Ministry of Health, PAHO, and the WHO women’s health policies and guidelines for sexuality, gender, and violence against women; Emotional support and counseling of persons who experience trauma; Advanced practice nursing in the setting of institutions that prevent, inhibit, and punish violence against women; Advanced practice nursing for ensuring sexual and reproductive rights.

The guiding principles of production of knowledge, technological development, and health care management consists of three courses. Their focus will be the analysis of clinical epidemiology principles and practices; planning, managing, implementing, and assessing research study designs; and the assessment of outcomes in care processes. This guiding principle will provide competencies for planning, developing, testing, and recording decision-making algorithms, software programs, and artifacts; and competencies for the use of communication and information technologies (CIT), focusing on an innovative and transformative practice. Discipline will be: Research methodology and clinical epidemiology applied to advanced practice nursing in women’s health; bases, methods, processes, and technologies in nursing and health; Quality tools applied to advanced practice nursing.

The Program’s course load will be divided into eight theoretical courses and three theoretical/practical courses, which will serve as a framework for the Program’s main guiding principles and research lines. Theoretical and theoretical/practical courses will provide APN clinical competencies, as well as the overall competencies of a master’s degree program.

Assessment will ascertain students’ development of critical thinking abilities and their capacity to incorporate new knowledge and propose creative, innovative, and transformative solutions aligned with national health policies and evidence-based practice. Assessment will be continuous, individual, and based on attendance, written test performance, class participation, field work, seminars, critical reviews, problem-solving, and designing a research project that is potentially transformative of women’s and newborn health practices. The final grade will be distributed among these assessment strategies.

Research lines will serve as a foundation for investigations. They will both feed on and guide the program’s course disciplines, and are listed below: Advanced practice nursing in antenatal, natal, and postnatal period: health improvement and well-being; Advanced practice nursing in sexuality, gender, and domestic and sexual violence prevention settings: health improvement and well-being; Exploring advanced practice nursing in caring for women and the newborn at risk: a critical stance; Development and use of technologies in the care of women and newborn.

The “Advanced practice nursing in antenatal, natal, and postnatal periods: health improvement and well-being” course will consist of the development of innovative and transformative research studies, projects, and programs for the advanced care of women and their children in antenatal, natal, and postnatal periods. The aim of the course will be to develop Brazilian maternal and neonatal health indicators in order to achieve those proposed by the WHO/PAHO and Brazil’s Ministry of Health.

The “Advanced practice nursing in sexuality, gender, and domestic and sexual violence prevention settings: health improvement and well-being” course will consist of the development of innovative and transformative research studies, projects, and programs for the care of women in the setting of reproductive planning and the free exercise of their sexuality and gender identity. The aim of the course will be to develop Brazilian health indicators to achieve those proposed by the WHO/PAHO, Brazil’s Ministry of Health, and other civil society, legal, legislative, and government organizations.

The “Development and use of technologies in the care of women and newborn” course will consist of studying the development, technological assessment, implementation, and implications of the use of devices, decision-making algorithms, medication, software programs, and other technologies to promote women’s and newborn health and well-being. The course will focus on a transformative action over health indicators.

Program duration, credit-hours, applications for admission, and final thesis

The Program will last for 24 months and students will have to fulfill a minimum of 25 credit-hours in theoretical and theoretical/practical courses, in addition to the writing of a dissertation.

The dissertation must be related to the purpose of the Professional Master’s degree program and to the student/health care provider’s area of practice/expertise. It may take on one of various forms, such as research studies, intervention projects, development and/or implementation of care and management protocols, and development of technological products (including but not limited to software programs, decision-making algorithms, and artifacts) in the context of women’s care. The dissertation must result from a research project and deliver a product aligned with APN characteristics. This product must be innovative, able to respond to social demands, and transform practice.

Admission process will include a test on overall women’s health and women’s health public policies based on literature references previously made available to all candidates; candidates will be required to submit a research project within the scope for the dissertation, and a CV. Candidates will also undergo an personal interview and an English proficiency test.

Obstetric nurses, midwives, and family health strategy, public health, and prenatal nurses will be considered eligible candidates. Candidates must fulfill the program’s pre-requisites. Given that one of the program’s goals is to increase autonomy of nurses in antenatal, natal, and puerperal periods, candidates must have previous education and work experience in the field. To increase autonomy and safety in clinical decision-making, the student/health care provider will experience a wide variety of childbirth and puerperal periods, including birth centers and home deliveries.

Obstetric nurses and midwives will be required to provide proof of previous work experience in the antenatal and natal periods. Family health strategy, public health, or primary care nurses will be required to provide proof of previous work experience in the antenatal and postnatal care settings. Only certified providers who are authorized to provide care in the childbirth setting will be allowed to practice within the program.

Infrastructure, IT resources, and library

The development of a professional master’s program requires an infrastructure consisting of proper facilities for classes, study rooms, meeting rooms, videoconference rooms and equipment, IT labs for students and faculty, Wi-Fi network, and multimedia resources for students and faculty within classrooms and other facility areas. A physical library will be available for its collection consultation as well as space for study. The library collection will consist of books, journals, dissertations, and thesis in health, nursing, and related areas, as well as data research and analysis center. The collection must be available both physically and electronically, and electronic resources must be easily accessible for students.

Teaching and research labs will be required, as well as partnerships with care institutions associated with women’s care, where students will have the clinical experience required to reach the Program’s goals. Partnerships with institutions that inhibit and punish violence against women, discrimination against gender and transgender people, and provide care and support to women who experience trauma and discrimination will also be required to achieve the program’s goals.

Discussion

Given the scope, the epidemiological relevance, the needs, and Brazil’s Ministry of Health, PAHO and the WHO policies stimulating us to collectively face the challenges in Women’s Health, in addition to the lack of a program for APN education, there is clear space for such type of program, especially considering the need to advance the production of knowledge that can be applied to women’s health. MEPASM seeks to develop competencies for intervention and positive transformation of overall health and production of technologies aligned with local needs. This search reflects the goals of a Professional Master’s Program and APN principles.

A significant portion of academic graduate students comes from outside the academy and seeks, in fact, not to become researchers, but trained professionals. Academic master’s are often the only possible option for these students, given the absence of professional graduate programs.

MEPASM’s proposal is precisely to work with these health care providers, bringing an effective training to the health workforce to achieve high performance, advanced and transform health care. The Program’s focus is the development of applied research, a vast demand in many sectors outside academia. The Program’s aim is to add quality to care and to develop and perfect improvement projects and public policies that improve women’s health and well-being indicators.

ICN has largely contributed to the progress of APN by conceptualizing it, specifying its required training, defining its roles, and regulating its practice. This has strengthened the advancement of the profession worldwide. ICN recommends educational preparation at an advanced level (master’s degree for entry level), formal recognition (accreditation) of programs preparing nurse practitioners for advanced practice, and a formal system of certification, registration, and credentialing. APN education, roles, and regulation should be aligned with and each country’s legislation specific to advanced practice nurses and also with the International Council of Nurses.(⁴)

The characteristics of APN practice are: integration of clinic, research, education, and management; high degree of professional autonomy and independent practice; case management skills; authority to admit their own patients; advanced health assessment skills; decision-making skills and diagnostic/clinical reasoning skills; recognized advanced clinical competencies; provision of consultant services to health providers; skills in planning, implementation, and evaluation of programs; and recognition as first point of contact for clients.(⁴)

APN’s country-specific regulatory mechanisms are: right to diagnose; authority to prescribe medication; authority to prescribe treatment; authority to refer clients to other professionals; legislation to confer and protect the title of APN; legislation or some other form of regulatory mechanism specific to advanced practice nurses; and officially recognized titles for nurses working in advanced practice roles.(⁴)In Brazil, obstetric nurses have authority to admit and release hospital patients and to sign a Certificate of Live Birth.

The two main APN roles are clinical nurse specialist (CNS) and nurse practitioner (NP). These roles have not been officially translated into Brazilian Portuguese. CNSs often have greater responsibilities over non-clinical activities, such as educating colleagues or quality improvement of care through the development of protocols and policies etc. NPs tend to have greater involvement in clinical care (provision of care to women), which gives them the authority to autonomously order diagnostic tests, make diagnoses, and prescribe treatments and medications.(⁹) Obstetric advanced practice nurses may act as CNSs or NPs, as there is professional room and laws for the performance of both roles. MEPASM was designed to promote the performance of both roles.

Our current setting inspires us to work together in expanding the role of nurses in Brazil by developing training and regulation and defining roles for the implementation of advanced practices. The fields we consider the most prepared to receive APN implementation are obstetric nursing and community nursing (primary care), given the initial clinical education (especially through residency programs) and roles that are already standardized, in addition to the legal support afforded by Brazil’s Ministry of Health Professional Practice Law.

Women’s Health entails diverse and complex actions in the whole life cycle including but not limited to prevention and rehabilitation of diseases, promotion of physical and mental health, choice of conception and maternity, free exercise of sexuality, insertion of women in the job market, understanding gender and violence against women as social constructs. Women account for over half the population, nearly half the job force, and they have great influence over family care and in preparing new generations.

ICM has set four essential competencies and the minimum set of knowledge, skills, and professional behaviors required for obstetric nurses. These requisites are also recommended by the WHO. The document outlines the general competencies for the areas of pre-pregnancy and antenatal care, care during labor and birth, and postpartum and neonatal care.(¹⁰)

The obstetric nurse/midwife is expected to: 1) assume responsibility for their own decisions and actions as an autonomous practitioner; 2) assume responsibility for self-care and self-development as an obstetric nurse/midwife; 3) appropriately delegate aspects of care and provide supervision; 4) use research to inform practice; 5) respect fundamental human rights of individuals when providing obstetric or women’s health care; 6) adhere to jurisdictional laws, regulatory requirements, and codes of conduct for obstetric nursing practice; 7) facilitate women to make individual choices about care; 8) demonstrate effective interpersonal communication with women and families, health care teams, and community groups; 9) facilitate normal birth processes in institutional and community settings, including women’s homes; 10) assess the health status, screen for health risks, and promote general health and well-being of women and newborns; 11) prevent and treat common health problems related to reproduction and the newborn; 12) recognize abnormalities and complications and institute appropriate treatment and referral; 13) care for women who experience physical and sexual violence and abuse; and 14) provide pre-pregnancy and antenatal care.(¹⁰)

Overall, Brazilian obstetric nurses are aligned with the characteristics described by ICM, but there are gaps. MEPASM intends to fill the following gaps: professional autonomy, clinical competencies, accountability for continuous self-development, the habit of using research to inform professional conduct; home births in community institutions, and care for women who experience abuse and physical and sexual violence.

Nursing’s contribution to Women’s Health care in Brazil is already fairly significant. However, there are various demands that need to be fulfilled, including but not limited to a high rate of C-section deliveries; high maternal and early neonatal morbidity/mortality; early weaning; a high rate of teenage pregnancies; improper sexual education and the risks of unsafe abortion; high rate of obstetric, domestic, and sexual violence against women; discrimination of transsexual persons; issues pertaining to the climacteric; unassisted aging; a high rate of mood and anxiety disorders; and insufficient knowledge and implementation of national policies and guidelines for women. Various national and international programs and protocols are in place to address these issues, but these are yet to be fully explored by the academia and clinical health care providers as whole. As a consequence, there is little adaptation and implantation in Brazil of these programs and protocols.

On light of the existing gaps in Women’s Health, and considering health best practices, MEPASM’s first guiding principle will be to increase the obstetric nurse’s autonomy in antenatal, natal, and postnatal periods, thus humanizing labor conditions, reducing the number of C-sections, and lowering the rate of antenatal mortality. Its second guiding principle is to provide qualified care to women who experience violence, providing support, care, and empowering them throughout various services provided. Its last guiding principle is providing emancipatory care in the setting of sexual and reproductive health. APN training to aid women in exercising their own reproductive control includes increasing professional autonomy for nurses to council and suggest contraceptive methods, in addition to increasing competencies for nurses to provide care to transsexual women, to teach women to care for their own health, and to empower them with the right to experience their own sexuality.

ICN’s APN characterization also applies to nursing in Women’s Health. A recent study identifies autonomy in practice, leadership, expertise, and research skills as advanced practitioner attributes. According to the same study, clinician, clinical and professional leader, educator, consultant, manager, change agent, researcher, and auditor are among the professional roles fulfilled by APN nurses in women’s health.

MEPASM’s attributes and roles are aligned with ICN’s definition of APN, i.e., the Program will train providers to possess the abilities and clinical competence to make complex decisions, widen and perfect nursing practice, promote inclusion, and provide better care. In Brazil, nurses and obstetric nurses are already fulfilling a portion of these roles. However, education has not been standardized, professional recognition and proper compensation are lacking, and sometimes providers fulfilling these roles lack the competencies to do so. Developing the APN system in Brazil is an urgent issue.

Autonomy is central to APN. Autonomous practice in APN means that APNs are responsible and accountable for their own practice, able to independently provide care for women and their families, and that decision making needs to be independent and go beyond obstetric management.(¹¹)

APN leadership may be clinical or managerial. Clinical leadership is understood as the ability to support initiatives that perfect clinical practice; it includes counseling and coordinating multiprofessional teams, being an agent for change in the care of patients, taking on the responsibility for policies, as well as for the development and implementation of guides and protocols, formal training programs, in-service training, and refresher courses for multiprofessional teams focusing on changes in clinical practice. APNs act as preceptors for colleagues and students, encouraging learning and serving as role models for autonomous decision-making and professional development. APN managerial leadership means teaching activities, developing policies, and engaging in professional committees, thus going beyond of the individual sphere of work and reaching national and international levels. It may also mean involvement in developing educational curricula. Additionally, awareness of political factors and factors affecting care and the profession is considered a pre-requisite.(¹¹)

Expertise is a vital attribute of APN practitioners. Advanced practitioners must possess broad and depth general knowledge and solid practice experience.(¹¹)

Research skills is part of APN competencies, and this may be learnt by performing single research and/or collaborative and group research projects, by the consuming of research and the ability to apply research into practice.(¹¹)

The analysis of MEPASM’s proposed courses and research lines show they were purposefully designed to aid students in acquiring the attributes of both an APN and a master’s degree, as well as preparing them to fully fulfill their roles. The courses and research lines cover advanced clinical care, health care programs and policies, preparation for scientific research, and the use and development of technologies, therefore, reflecting all three of the Program’s guiding principles.

Theoretical/practical courses are paramount in a Professional Master’s Program that aim to develop APN, although they are not so relevant in academic master’s degree programs. In the Professional Master’s degree Program, the student is expected to incorporate new clinical competencies and develop a capacity for reasoning, making complex decisions, and autonomously providing care in the prenatal, delivery, and puerperal periods, including birth centers and home deliveries. This Program also aims at improving the care provided to women who are victims of violence and who face gender issues. Developing these competencies requires experience and critical thinking in scenarios that might be unusual in a typical in nursing education. An overall lack of understanding of the differences between goals and education processes of professional and academic master’s degree programs has resulted in a great number of professional master’s degree programs that are, in fact, academic only.

Both scientifically and technologically, a professional master’s degree is meant to empower practitioners to analyze reality and implement public policies, to develop and implement clinical protocols, and to propose technological solutions. The aim of the program is to develop a transformative practice that adheres to advanced practice nursing and evidence-based practice models.

Conclusion

There are many opportunities to improve women’s care in several areas, such as promote the obstetric nurse’s decision-making autonomy in antenatal, natal, and postnatal periods; expand competencies for the fight against domestic and sexual violence against women; and improve professional training for provision of care to contribute for women freely exercising of their sexuality and gender identity. The exercise of this new area, if based on principles of autonomy, high clinical competence, qualified leadership, and research skills, will improve women’s care in these areas and they should transform practice for nurses, consequently, nurses may expand their roles beyond what is expected from them in their initial education and explore the field of APN. The Professional Master’s Program in Women’s Health in Advanced Practice Nursing (MEPASM) is expected to contribute to the dissemination of APN, promote similar programs within academia, and encourage professional associations to support changes in legislation and regulation for this new role, as well as incorporate these new provider’s profile in the job market.

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Publication Dates

• Publication in this collection
  19 Oct 2020
• Date of issue
  2020

History

• Received
  1 June 2020
• Accepted
  20 Aug 2020