ADVANCED PRACTICE NURSING IN CANADA: REFLECTIONS ON THE IMPLEMENTATION PROCESS IN THE BRAZILIAN CONTEXTABSTRACT
Objective: to reflect on the implementation of the role of Nurse Practitioner (NP) in Brazil, based on aspects considered important in the perspective of implementing this role in the country, based on previous experiences in the province of Quebec, Canada.
Method: this is a theoretical-reflective study based on information obtained from technical-scientific literature and documents, laws, draft bills or historical records of governmental organizations or nursing councils, considering Canada/Quebec and Brazil as the context of analysis. Based on this, the study is structured around three main axes: historical aspects of the implementation and regulation of the NP role in Quebec; aspects of NP training; and possible challenges and paths in the perspective of implementing this role in the Brazilian context.
Results: it is possible to observe similarities between the current situation in Brazil and what nursing experienced in Canada around 60 years ago, particularly in relation to the search for health care for people, especially in remote areas. The Quebec experience shows that the implementation of the NP role has been procedural, with the incorporation of different documents and actions over the years to ensure both guidelines aimed at training and regulating this role, as well as contributing to the inclusion of these professionals in the health system.
Final considerations: bringing together experiences from the implementation of the APN in other places, in this case with the context of Quebec in particular, is important in defining the best paths for the health care of the Brazilian population.
DESCRIPTORS:
Nursing; Advanced practice nursing; Primary health care; Education; Health Human Resource Training
RESUMO
Objetivo: refletir sobre a implementação do papel de Nurse Practitioner (NP) no Brasil, a partir da abordagem de aspectos considerados importantes na perspectiva de implantação deste papel no país, tendo como base experiências prévias da província de Quebec, Canadá.
Método: trata-se de estudo teórico-reflexivo realizado a partir de informações obtidas na literatura técnico-científica e em documentos, leis, projetos de lei ou arquivos históricos de organizações governamentais ou conselhos de enfermagem, considerando como contexto de análise o Canadá/Quebec e o Brasil. A partir disso, o estudo se estrutura em três eixos principais: aspectos históricos da implementação e regulação do papel de NP no Quebec; aspectos da formação do NP; e possíveis desafios e caminhos na perspectiva de implantação deste papel no contexto brasileiro.
Resultados: é possível observar similaridade entre o momento atual brasileiro com o que foi experimentado pela enfermagem no Canadá há cerca de 60 anos, particularmente com relação à busca pela atenção à saúde das pessoas, sobretudo em áreas remotas. A experiência do Quebec demonstra que a implementação do papel do NP foi processual, com incorporação de diferentes documentos e ações ao longo dos anos para assegurar tanto diretrizes voltadas à formação e regulamentação deste papel, quanto para contribuir com a inclusão destes profissionais no sistema de saúde.
Considerações finais: a aproximação com experiências oriundas da implantação da EPA em outros locais, neste caso, com o contexto de Quebec em especial, é importante para definição dos melhores caminhos em prol da atenção à saúde da população brasileira.
DESCRITORES:
Enfermagem; Prática avançada de enfermagem; Atenção primária à saúde; Educação em enfermagem; Capacitação de recursos humanos em saúde
RESUMEN
Objetivo: reflexionar sobre la implementación del rol de Enfermero Practicante (NP) en Brasil, abordando aspectos considerados importantes desde la perspectiva de la implementación de ese rol en el país, a partir de experiencias anteriores en la provincia de Quebec, Canadá.
Método: estudio teórico-reflexivo realizado sobre la base de informaciones obtenidas en literatura técnico-científica y en documentos, leyes, proyectos de ley o archivos históricos de organizaciones gubernamentales o consejos de enfermería, considerando Canadá/Quebec como contexto de análisis. En ese marco, el estudio se estructura en torno a tres ejes principales: aspectos históricos de la implementación y regulación del papel del NP en Quebec; aspectos de la formación de NP; y posibles desafíos y caminos en la perspectiva de la implementación de este rol en el contexto brasileño.
Resultados: es posible observar similitudes entre el actual momento brasileño y lo vivido por la enfermería en Canadá, hace alrededor de 60 años, en particular, en lo que se refiere a la búsqueda de atención a la salud de las personas, especialmente en áreas remotas. La experiencia de Quebec demuestra que la implementación del rol del NP fue procedimental, con la incorporación de diferentes documentos y acciones a lo largo de los años para asegurar directrices orientadas a la formación y regulación de este rol, y para contribuir a la inclusión de estos profesionales en el sistema de salud.
Consideraciones finales: el abordaje de experiencias derivadas de la implementación de la Enfermería de Práctica Avanzada en otros lugares, en este caso, en el contexto de Quebec en particular, es importante para definir el mejor camino hacia la atención de la salud de la población brasileña.
DESCRIPTORES:
Enfermería; Enfermería de Práctica Avanzada; Atención primaria de salud; Educación en enfermería; Capacitación de Recursos Humanos en Salud
INTRODUCTION
Health systems have faced considerable challenges in being able to respond adequately and sustainably to the health needs of populations1-2. Most of these needs are due to the increase in chronic conditions and an ageing population1-2. Among the challenges also experienced by health systems in this context is the lack of health professionals and/or their unequal geographical distribution, which implies difficulties in accessing health care services, especially in rural areas1-2. In this sense, the implementation of Advanced Practice Nursing (APN) has been considered as a possible strategy to help overcome these challenges and strengthen health systems1-2.
The APN is an internationally recognized term that brings together different roles, the common principle of which is the performance of advanced practices in the provision of health care by nurses who are thus trained and qualified3. The advanced practice nurse is a nurse who, through a specific training process that enables him to act in this role, has acquired knowledge and developed a set of skills so that he can, with greater autonomy, manage complex health problems considering his area of specialty, while at the same time acting as a leader and mentor in favor of continuous professional development and improvement of nursing care practices3-4.
Therefore, it is recommended that advanced practice nurses be trained to at least a master's degree level and that regulatory mechanisms be in place to guide the accreditation of training programs or institutions, certification and licensing, ensuring a legally protected title and authorization to practice3.
The roles reported by the International Council of Nurses within the APN are Clinical Nurse Specialist (CNS), Nurse Practitioner (NP), Nurse Anesthetist and Nurse-Midwife, the first two being the most common3. In Quebec, there are different professional categories in nursing, including advanced practice nurses: the NP (from the French, infirmier praticien spécialisé or infirmière praticienne spécialisée - IPS1*); and CNS (from the French, infirmiers cliniciens spécialisés - ICS)5,6-8.
Clinical Nurse Specialist (CNS)
The CNS's scope of action includes a particular specialty or field of practice, in which direct and/or indirect care is provided3. Direct care includes, for example, the work of the CNS with patients and families through comprehensive care and interprofessional collaborative work during the assessment, diagnosis and treatment of health conditions4. Indirect care includes the role of the CNS in the clinical management of cases in a health care network context and as a consultant in the management of complex problems, assisting the team in providing evidence-based health care3-4. The CNS evaluates patient outcomes to identify clinical improvements, influences nursing practice through leadership, education and research, and may or may not have some prescribing authority in their area of expertise3.
Nurse Practitioner (NP)
The NP's scope of practice is wide-ranging, enabling them to clinically assess patients and propose a care plan which generally includes prescribing therapeutic resources and medication and monitoring the patient3. As such, they focus on providing direct clinical care to patients by carrying out health assessments, differential diagnoses, prescribing, diagnosing and managing treatment3. These clinical activities are carried out by the NP autonomously and/or shared with other health professionals3. They therefore work to solve a variety of problems and generally have the authority to prescribe treatments, admit and refer patients3. The NP's scope of practice also includes professional education, research and leadership activities3.
In this sense, it is worth highlighting the results of international scientific literature on the implementation of NP and CNS roles in health systems2,9. A systematic review study shows that the involvement of advanced practice nurses in patient care in the emergency and intensive care sectors improves length of stay in the sector, patient satisfaction and favors cost reduction9. In the case of the NP role, training programs develop skills that enable NPs to carry out a considerable number of interventions that do not require medical evaluation, helping to increase consultation times, improve access to healthcare and decongest the healthcare system10-11.
However, some countries have faced difficulties in implementing the role of advanced practice nurse in their health systems, including Latin American countries such as Brazil2,12. Most of the time, these difficulties stem from the lack of definitions regarding the training required for APN and the absence of regulatory frameworks to guide professional practice and the inclusion of these roles in health services12. In countries such as Australia, Canada, the United States, Hong Kong and New Zealand, the role of advanced practice nurse has been a reality for years12-13. The experiences of these and other countries in the process of implementing APN can support discussions and demonstrate ways to contribute to faster progress in the inclusion of this role in the health care of the population in other places14. In 2018, the Pan American Health Organization (PAHO) published a document containing steps and activities to implement the APN in countries12. One of the steps is the planning of implementation strategies, which envisages as an activity, in fact, the referencing of other countries' experiences regarding the regulation and implementation of the APN12.
In view of this, it was decided to analyze the development of the APN in Canada, especially the role of the NP in Quebec, as it is one of the pioneering countries in this implementation in search of expanded care, especially in rural or remote areas, which corroborates the current discussions in Brazil, as they also include expanding access to health care as one of the factors1,5,13,15. In addition, considering the discussions on the subject in Brazil, which involves the context of Primary Care1 - which represents a diversified practice for the health care of various population groups - this work adopts as a delimitation the role of NP.
The aim of this article is therefore to reflect on the implementation of the NP role in Brazil, by looking at aspects considered important in the perspective of implementing this role in the country, based on previous experiences in the province of Quebec, Canada. To this end, the study takes on a theoretical-reflective character and is based on information from technical-scientific literature and documents, laws, draft bills or historical records from government organizations or nursing councils, considering Canada/Quebec and Brazil as the context of analysis, consulted through a free search by the authors until October 2023. It discusses the process of implementing the NP role and the bases for the work of this professional in Quebec, as well as characteristics of the organization of nursing in Brazil, to reflect on aspects seen as important from the perspective of implementing the NP role in the Brazilian context. With this in mind, the structure of the text comprises: 1) a presentation of historical aspects related to the implementation and regulation of the NP role in Quebec, 2) information on the training of NPs, and 3) a reflection on possible challenges and ways towards the implementation of the APN role in Brazil.
HISTORICAL ASPECTS OF THE IMPLEMENTATION AND REGULATION OF THE ROLE OF THE NURSE PRACTITIONER
More formal recognition of the role of advanced practice nurses in Canada dates back to the 1960s, with the work of nurses providing extended care in rural or remote areas where the medical workforce was scarce, for example in Canada's remote northern regions5,13,15.
Thus, for the role of advanced practice nurses to emerge and be defended, it was necessary for key individuals in the health system to identify APN as a relevant solution to the difficulties observed in access and continuity of health care for the population16.
Although the first experiences of training nurses with expanded functions date back to around 1970 in Quebec, it was in the 1990s that academic institutions turned their attention to creating the necessary programs to prepare NPs to work in the province, also under the influence of the 2002 Bill No. 90, which incorporated changes to the code of professions and other legal provisions in the health area17. This bill provided for a framework that would allow other non-medical professionals, namely nurses, to be authorized to carry out certain medical activities, including: 1) prescribing diagnostic tests; 2) using diagnostic techniques that are invasive or pose a risk of harm; 3) prescribing medicines and other substances; 4) prescribing medical treatments; and 5) using techniques or applying medical treatments that are invasive or pose a risk of harm17-19.
In the 1990s, pilot projects in neonatology were identified at the McGill University Health Center and the Sainte-Justine University Hospital Center, both in the city of Montreal, among the first experiences of NP work16-17. In 2003, the provincial government announced a budget to create new jobs for NPs in three specialties: cardiology, neonatology and nephrology, with the aim of supporting the implementation of this role17,19. Of this budget, a portion would be dedicated to scholarships for NP candidates, with the aim of supporting them during their training17,19.
In 2005, the College of Physicians and the Order of Nurses adopted joint guidelines that provided the legal framework for the practice of NPs, based on five regulations: 1) regulation on the activities envisaged in the Medical Act that can be exercised by non-medical professionals; 2) regulation on the specialty classes for the exercise of specialized activities envisaged in the Nurses Act; 3) regulation on training commissions; 4) regulation to change the modalities for the sale of medicines, with a view to formalizing the role of prescriber; and 5) regulation on degrees issued by educational institutions that allow access to certification as a specialist nurse19-20.
The following year (2006), the first certification exam was held for NPs in the specialties of cardiology, neonatology and nephrology19. Also in 2007, the training program for the NP specialty in primary care began19. This led to the adoption of guidelines for the work of NPs in primary care from 2008 onwards19. In 2017, NP training in adult care began, followed by training in mental health and pediatric care19. New investment was made by the government in 2017, with the aim of promoting the education of NPs for the insertion of up to 2,000 NPs within the health system for the years 2024 and 202517. In addition to these investments, there have been other fronts, such as financial transfers to doctors who establish collaboration or partnership agreements with NP17.
Over the years, legislative changes have led universities to seek strategies to expand new classes of NP specialties and new activities have been included in the NP role, promoting greater autonomy in their work6,17,19,21. Among these changes was Bill No. 4322, which proposed expanding the list of activities that NPs could carry out to promote access to health services. This Bill amended the Nurses' Law, other laws and regulations, especially in terms of assistance to individuals and families, and health and safety at work, to allow NPs to carry out practices previously reserved for doctors, such as diagnosing common illnesses and recommending certain medical tests or treatments22,23.
This movement led to eight activities being carried out by NPs, in addition to those that were already the responsibility of nurses6,21. These activities must be carried out in accordance with the class of specialty and the conditions established in the regulations governing the role of NPs6,23, and include6,21,24: 1) Diagnosis of illnesses; 2) Prescription of diagnostic tests; 3) Use of invasive diagnostic techniques or those with a risk of harm; 4) Determination of medical treatments (physiotherapy, compression stockings, others); 5) Prescription of medicines and other substances (the NP does not have a specific list of what he can prescribe, apart from a few exceptions, so prescriptions are made according to his specialty, knowledge, skills and the patient's condition); 6) Prescription of medical treatment (it is possible for the NP to fill out a certificate and indicate interruption of work or return to work for educational establishments, police or fire schools, and others); 7) Use of techniques or application of invasive medical treatments or those that present a risk of harm (biopsy, intubation, and others); and 8) Monitoring of pregnancies.
When providing care to the patient and/or family, other professionals may be called upon by the NP, such as psychologists and nutritionists, partner doctors, clinicians or specialists, to provide interprofessional care in collaboration with the NP11. In addition to their duties in clinical practice, the NP works on complementary activities (around 20 to 30% of their time or one day a week), including: collaborating on the drafting of clinical protocols/guidelines, leadership and participation in professional organizations24.
The implementation of the NP's role occurred gradually in the context analyzed, with specialties expanding over the years, so that five classes of specialties were recognized: 1) adult care; 2) mental health; 3) primary care; 4) pediatric care; and 5) neonatology18-21,23.
CHARACTERISTICS OF NURSE PRACTITIONER TRAINING
The decision to start training to be an NP in Quebec is possible for nurses who, after completing their undergraduate nursing program, have taken an exam to determine their aptitude to practice the profession and have then practiced nursing for at least two years, one year of which was in their field of specialty7. University training to work as an NP combines a master's degree in nursing science and a diploma of specialized studies in one of five specialties7. On completion of the training, the nurse is awarded the title of candidate for the role of NP, and is able to exercise the function after passing the certification exam, which brings together questions based on clinical reality and regulatory aspects related to the practice of NP in the specialty7.
An example of NP training in the primary care specialty is described below. Laval University offers both a master's degree in nursing and a diploma of higher specialized studies (DESS)25. Training can take place over two years, if full-time, or three years, if part-time25. In the two-year course, the weekly workload varies from 27 to 45 hours, depending on the period of the year, with the final stages reserved for internships and the completion of the internship report25. Nurses are supported during their training by a teaching team, and supervision in practical activities is carried out by specialty NPs and family doctors25. During the training course, topics such as pathophysiology and diagnostic measures, advanced pharmacology, clinical examination of people in the different life cycles, treatment of common health problems, education, research and ethics, among others, are covered, in addition to internships25.
ASPECTS RELATED TO THE BRAZILIAN CONTEXT
In Brazil, there are the categories of nurse, nursing technician, nursing assistant and midwife26. These categories are regulated by Law No. 7,498 of 1986, which regulates the practice of nursing in the country26. Thus, nursing can be practiced in the country by professionals in the categories described, respecting their respective degrees of qualification, and as long as they are registered with the regional nursing council with jurisdiction over the place where the profession will be practiced26.
According to data from the Federal Nursing Council (COFEN), on July 1, 2022, there were 666,555 active registrations of nurses with the Council, 1,595,941 nursing technicians and 447,578 nursing assistants throughout Brazil27; however, there are inequalities between regions regarding the availability of professionals, occupation of jobs and the existence of educational institutions13.
In the Brazilian nursing team, the nurse is the only professional with undergraduate training, which varies from 4 to 5 years depending on the curriculum of the university program. With this training, nurses assume responsibility for leading the nursing team, providing direct care to patients, carrying out nursing consultations and prescribing medication or tests in accordance with nursing protocols and professional guidelines, and carrying out more technically complex nursing procedures.
It should be noted that, in Brazil, the control and supervision of the exercise of the profession is the responsibility of the Nursing Councils (national and regional)28. Among the competencies of the Federal Council is to issue instructions for the uniform operation of the regional councils and to resolve doubts arising from these councils28. The powers of the Regional Councils include the act of deciding on the registration of professionals and their cancellation, disciplining and supervising the exercise of the profession, and deciding on issues related to professional ethics, imposing appropriate penalties28.
Brazil still has spaces for training nurses at master's level, such as professional and academic master's degrees1. However, although professional master's programs aim to train nurses capable of intervening in their workplaces, theoretical training has prevailed in these programs, with no focus on advanced clinical training in terms of pathophysiology, pharmacology, clinical reasoning and other content that is important for making autonomous therapeutic decisions1.
REFLECTIONS
The discussion regarding the implementation of the APN in Brazil has intensified in recent years, with the support of nursing organizations such as the Brazilian Nursing Association (Associação Brasileira de Enfermagem, ABEn) and the Conselho Federal de Enfermagem (COFEN)1,13-14. Similarly to what was observed in the process of implementing the APN in Canada5,13, discussions in Brazil have included the potential role of advanced practice nurses in the health care of people in remote areas or areas marked by poorer results in health indicators1,13-14. This fact has led to analysis to identify which Brazilian regions are most in need of advanced practice nurses, with a view to increasing access and resoluteness in health services in these locations, especially in Primary Health Care13.
Thus, based on Quebec's experience in implementing the role of the NP16, the recognition of the NP's potential to strengthen the health system, by professionals and managers, is considered a decisive point for advancing discussions on the implementation of this role in the national context. These potentials include improving the population's access to health care, especially in areas with a limited supply of doctors, as well as the possibility of improving care by intensifying monitoring and counseling for people with chronic conditions and reducing health costs15. In this perspective, the scientific literature also reports, through a systematic review, the evaluation of the performance of tasks associated with the role of the doctor by nurses, in the context of primary care services, pointing to favorable results regarding patient satisfaction, hospital admission indicators and mortality29.
In the absence of knowledge/recognition about the role of the APN and its contributions to the health system, efforts may not be enough to overcome the barriers that may mark the initial implementation proposals.
Quebec's experience shows that the process of implementing the NP role has been discussed and consolidated over the years, and that efforts remain to broaden and regulate the scope of practice, taking into account the different specialties6,17,19,21. It is understood that a fundamental milestone was the establishment of laws and normative documents that recognized the position and duties of the NP, as well as determining the criteria to be adopted by university institutions for training these professionals and taking the certification exam6,17-22.
In this way, it is considered that, once the relevance of the NP's role in the health system has been identified, it is important to recognize this professional category as a member of the nursing team at national level, structuring specific regulations that deal both with the guidelines for training, evaluation of skills / competences and certification at national level, as well as supporting the activities inherent in clinical practice, including attributions, ethical and professional career provisions (for example, remuneration).
The International Council of Nurses considers it ideal to have mechanisms that allow for the protection of the title and a definition regarding the scope of practice or work of the NP3. The NP title should be considered a requirement, as it ensures distinction between an NP and other professional categories of the nursing team, as well as preventing the duties of an NP from being performed by professionals not qualified for such functions3.
As this is a group of specialized nurses who have an expanded scope of practice, that is, who perform other activities in addition to those already delegated to nurses, and who, due to their degree of complexity, pose a greater risk to patients3-4, training for the title of NP deserves special attention. At this point, the Quebec experience suggests that the training of advanced practice nurses requires compliance with a set of criteria by certified university institutions in order to prepare them for the exercise of this role, in addition to tools for assessing the training process and the competencies and skills of nurses that allow the conferral of the title and the performance as an NP6-7. It is considered important, as far as possible, to standardize the role of the NP in relation to the international context, to facilitate collaboration, migration, recognition and action in other countries.
In any case, Brazil has a high level of access to postgraduate studies, so that, in the future, it could offer the necessary training and contribute to the insertion of NP in health systems12. On the other hand, similar to the experience of implementing APN in Chile4, it is considered that the support of doctors and/or international support may be fundamental for the training of NPs in Brazil, especially at the beginning, due to the lack of NPs who can support the training of other NPs in the country.
It is also important to understand the role of these nurses and the criteria or models for their training, based on existing guidelines and experiences, and the characteristics of Nursing in Brazil1. In this context, it is important to understand how the training processes occur at the undergraduate level, since the training time, as well as its objectives and didactic-pedagogical structure, may imply adaptations in relation to the training of the NP, with regard to the focus and training time. In Brazil, nurses are trained in undergraduate courses (bachelor's degrees) that are completed in 4 or 5 years; in Quebec, in turn, the bachelor's degree in nursing generally lasts 3 years7.
In Quebec, training programs for NPs were proposed by university institutions as progress was made in recognizing this role in the province; and, as a result, they were able to be aligned with the guidelines regarding the role of these nurses17,19. Although the existence of regulatory mechanisms for subsequent training based on these mechanisms is considered ideal, it is understood that the process can sometimes occur simultaneously, through training aligned with a concomitant articulation.
Thus, in the context of implementing APN in Brazil, it is necessary to define which role will be implemented (whether NP or another), which specialty and which training model will be adopted, considering what is expected of these nurses as competencies for professional practice - according to international guidelines and experiences - and the national priority areas13. It is important to highlight the importance of countries seeking to establish APN having a clear understanding of the professional's competencies regarding their role and functions to be performed30.
There are also discussions to be held regarding the definition of criteria that allow for the accreditation, regulation and monitoring of institutions responsible for training these nurses; and regarding the existence of exams for certifying nurses in their specialty and who would be responsible for this responsibility. At the same time, strategic efforts are important to broaden debates that culminate in the definition of a theoretical, political and labor framework that legitimizes the performance of these nurses in the health system once they are trained and qualified13. Nursing councils (national and regional) could actively participate in this process, given their involvement in the control and supervision of nursing practice in Brazil28, exercising similar attributions to the Order of Nurses6.
CONCLUSIONS
Although the defining characteristics of APN are widespread internationally, experiences of implementing the role of advanced practice nurse vary between countries according to the specific aspects of each country and its health and population needs12. As they have already gone through APN implementation movements, collecting successful and complex experiences, they can contribute to other interested places getting closer and learning from these experiences14. In this article, the experience of implementing the APN in Canada, with emphasis on Quebec and the role of NP was approached, since it includes in its history a particularity that is a challenge for Brazil in achieving universal health coverage, that is, the unequal distribution of professionals and the need for strategies for the care of the population, especially in rural or remote areas1. In this sense, the approach to the experience of implementing the APN in Canada suggests that the process was a response to the needs of its patients, and this same logic is important to define the implementation of the APN in Brazil, seeking to discuss which problems or needs could be resolved through this process12.
In general, the Quebec experience demonstrates that the implementation of the NP role is an ongoing process of seeking to incorporate and strengthen this role in the health system, including, to this end, the proposal of new provisions that contain guidelines and that ensure aspects understood as fundamental for ethical and safe training and performance in the exercise of advanced practices, as well as to monitor, supervise and evaluate the insertion of this role in the health system.
It is possible to observe potential for the adoption of the NP role in Brazil, but also important challenges in terms of training and implementation of this role in the health system. The importance of defining provisions to clarify the eligibility of nurses applying for NP training, requirements for training programs, guiding them on the objectives, curricula and training path, guidelines on the certification process, aptitude assessment, and professional registration, as well as guidelines for exercising the role of the APN in terms of ethics, clinical practice and career organization is recognized. These aspects require the search for consensus on the paths to be taken, through discussion and planning involving different interested parties, such as the Nursing Council, Nursing Associations, Universities, Ministries of Health and Education and civil society.
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