Nursing in Portugal in the National Health Service at 40

We describe the development of nursing in Portugal since the creation of the National Health Service (SNS) in 1979, focusing on staff numbers, education, work conditions, career, and professional organization. We used the literature on the evolution of the Portuguese health sector and statistical data from the Nursing Council and the SNS. The number of nurses grew by 233% in the last 40 years, but the nurse/physician ratio only increased from 1.15 to 1.4. Most work in hospitals, despite repeated political commitments to expand primary health care. In the SNS, 55% are public servants, and the others are employed through private law contracts. The basic nursing course is currently offered in 20 public and 16 private institutions. In 2019, the career structure was revised and now comprises three categories: nurse, specialist nurse, nurse manager. Nurses remain moderately satisfied despite complaints about working conditions, remuneration, and lack of career progress. Nurses' role barely changed over the years, and the Medical Association is resisting to its expansion.

Key words
Nursing; Portugal; Evolution of the profession; Education; Working conditions

Authorship

Inês Fronteira

Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. da Junqueira 100. 1349-008 Lisboa Portugal. ifronteira@ihmt.unl.ptInstituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. da Junqueira 100. 1349-008 Lisboa Portugal. ifronteira@ihmt.unl.ptInstituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa. R. da Junqueira 100. 1349-008 Lisboa Portugal. ifronteira@ihmt.unl.pt

https://orcid.org/0000-0003-1406-4585

Élvio Henriques Jesus

Instituto de Ciências da Saúde, Universidade Católica Portuguesa. Lisboa Portugal.Instituto de Ciências da Saúde, Universidade Católica Portuguesa. Lisboa Portugal.Instituto de Ciências da Saúde, Universidade Católica Portuguesa. Lisboa Portugal.

https://orcid.org/0000-0002-8407-9240

Gilles Dussault

https://orcid.org/0000-0002-5976-3454

Collaborations

G Dussault conceived the initial structure of the manuscript; I Fronteira and EH Jesus have agreed and contributed to all stages of manuscript production.

SCIMAGO INSTITUTIONS RANKINGS

Tables

Tables (3)

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Chart 1
Family Health Units (USF): An Innovative Way of Accessing Primary Care.

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Chart 2
Recognition of the Family Health Nursing Specialty.

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Chart 3
Results of the RN4cast Portugal Study, 2017-18.

Chart 1 Family Health Units (USF): An Innovative Way of Accessing Primary Care.

In 2005, a reform broke with the traditional way of providing primary care by setting up Family Health Units (USF) in the SNS. New organizational modalities were promoted, such as teamwork, community orientation, autonomy, and administrative flexibility and performance evaluation. Typically, USFs comprise of an average of 20 professionals and technicians, forming a volunteer team of doctors and nurses, supported by 2-3 administrative secretaries. There is an average nurse/doctor ratio of 1.06, but there are low-ratio USFs with twice as many doctors as nurses. Each team is responsible for providing services to a population of 1,500 people per doctor (1,900 after the 2011 austerity measures), geographically defined. The USF signs a quality and service coverage objectives contract with its local Health Center Group (ACES), which is then approved by the Regional Health Administration (ARS) and finally by the Central Health System Administration (ACSS). Once the contract is approved, the USF receives resources such as infrastructure, equipment, and a budget. ACES also enables access to other professionals such as nutritionists, specialist nurses, or physical therapists.
Two USF models are in place: the new ones start as model A and then can become model B, with more demanding clinical objectives. Model B gives access to more resources and offers a pay-for-performance component. The first USFs began operations in 2007. In May 2019, there were 281 Model A, 254 Model B, and 52 active applications for A and 75 for B. Management is participatory, and all decisions are taken collectively, all team members being considered as equals. USFs operate with greater administrative autonomy in a less bureaucratic way.
In the USFs, nurses work more collegially with doctors, participating in decisions and, in the case of Model B, benefiting from performance-related incentives. Nurses have more opportunities for professional development through continuing education activities, such as individual apprenticeship plans, reading groups, participation in conferences, and meetings to review performance indicators.

¹⁷17 Biscaia A, Heleno LVC. A Reforma dos Cuidados de Saúde Primários em Portugal: portuguesa, moderna e inovadora. Cien Saude Colet 2017; 22(3):701-712.

¹⁸18 Lapão LV, Pisco L. A reforma da atenção primária à saúde em Portugal, 2005-2018: o futuro e os desafios da maturidade. Cad Saude Publica 2019; 35(Supl. 2):e00042418.

Chart 2 Recognition of the Family Health Nursing Specialty.

With the creation of USFs, the issue of the recognition of the specific character of nursing in primary care emerged. Several years of debate preceded the recognition of the figure of "family nurse" as a member of family health teams by Decree-Law N° 118/2014 of August 5. This decree provided for experimental inclusion of such nurses in 30 USFs. As early as 2010, the Nursing Council had proposed a definition of family nurse responsibilities and tasks, and some nursing schools began offering specialization programs. However, due to the lack of consensus between the Council, the unions and the Ministry of Health on the content of family nurse work, until 2017, these pilot projects had not started.
The Council only recognized the family health nursing specialty as a sub-specialization area of community health in 2018.

²2 Simoes JA, Augusto GF, Fronteira I, Hernandez-Quevedo C. Portugal: Health System Review. Health Syst Transit 2017; 19(2):1-184.

Chart 3 Results of the RN4cast Portugal Study, 2017-18.

While very exhausted, nurses remain moderately satisfied, trust the care they provide, rank the care quality and safety as "good", remain very engaged, and want to stay in the profession. However, less positive aspects persist, namely:
• Unfavorable Work Environments (PES-NWI - Mean: 2.39 (Standard Deviation 0.41), especially regarding strands Participation of Nurses in the Organization's Governance - 2.11 (0.50); Adequacy of Human and Material Resources - 2.13 (0.60); and in Management, Leadership and Nursing Support - 2.13 (0.62), all below the cut-off point 2.50;
• Low Organizational Culture regarding safety. Respondents agree or are neutral regarding the following: "that their mistakes are used against them" (70.5%), "there is a low level of freedom to question the decisions or actions of their superiors" (68.7% disagree or take a neutral stance). They disagreeing or remain neutral with respect to "hospital/organization management interventions show that patient safety is a top priority" (63.2%);
• Perception of high workloads - 38.5% of participants (16 times higher) respond that they totally disagree, versus 2.3% who say otherwise when asked if there are enough nurses to provide quality care to patients;
• High levels of burnout, particularly in the Emotional Exhaustion (at least 55.3%) and Turnover (Intention to Leave Workplace) realms - 52%, but low rates of lack of personal accomplishment and depersonalization;
• Job dissatisfaction, especially regarding Salary (over 90%) and Career Opportunities (86.3%);
• High number of patients assigned to each nurse, taking into account the functional content, responsibility and staff mix in Portugal (on average, more than eight patients per nurse);
• High prevalence of some incidents (with clients and nurses), care left undone due to lack of time, and performing non-nursing "tasks" (e.g. answering phone calls, bureaucratic tasks).
In conclusion:
- Some favorable aspects regarding the perception of the quality and safety of care, despite the unfavorable practice environments;
- Incipient participation in the governance of organizations, adequacy of human and material resources and management, leadership and nursing support;
- Considerable regional and organizational variability in many of the indicators studied;
- Poorer rates in hospitalization contexts, in general, and when compared with previous results (2013/14), in the same type of services (medical-surgical);
- Lack of relationship or existence of unfavorable negative association in some of the studied indicators (e.g., adequacy of human and material resources, burnout, engagement...) with the reference of whether or not the organization is "Accredited for Quality";
- Nurses who, although exhausted, remain moderately satisfied (43.7%), very engaged with work (80.8%), and wish to remain in the profession (65.5%) against those who claim they wish to change organization (52.0%).

²⁴24 Jesus EH. Comunicação online dos principais resultados preliminares do inquérito RN4cast [página na Internet]. 2018 [acessado 2019 Fev 27]. Disponível em:https://www.facebook.com/rn4castportugal/posts/2225183454435829?__tn__=K-R
https://www.facebook.com/rn4castportugal...

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[1] Collaborations

G Dussault conceived the initial structure of the manuscript; I Fronteira and EH Jesus have agreed and contributed to all stages of manuscript production.