REFLECTION ARTICLE

Nursing in Advanced Practice in emergency care unit: a promising reflection

Francielli Aparecida Araújo1, Ana Paula Amorim Moreira1, Maithê de Carvalho e Lemos Goulart2

1Universidade Federal Fluminense, Niterói, RJ, Brazil

2Universidade Federal Fluminense, Rio das Ostras, RJ, Brazil

ABSTRACT

Objective: To reflect about the Emergency Care Unit an action scenario for the Advanced practice of nurses in emergency and urgency services. Method: This study utilized the methodology of reflection. Results: Advanced Practice Nursing is a specialty in which nurses with expanded knowledge and additional skills can make complex decisions in addition to having an advanced level of specific practices. Emergency and urgency services are promising scenarios for the development of Advanced Practice Nursing, including the 24-hour Care Unit, especially due to the capacity of high complexity care and the performance of highly qualified professionals. Therefore, there is a need for reflection on the advances, obstacles in the performance and regulation, especially in relation to this scenario, which is little discussed in the context of Advanced Practice Nursing in Brazil. Conclusion: There is a great need to expand the discussion of Advanced Practice Nursing to the other levels of care in Brazil. There are services with vast potential to be developed, one of them being the 24-hour Care units. It is observed that nurses from advanced practices in these services can bring great benefits to the population, in addition to improving the quality of care, bringing greater autonomy for nurses in these services.

Descriptors: Emergency Medical Services; Advanced Nursing Practice; Health Care; Public Health Nursing; Evidence-based Nursing.

INTRODUCTION

The area of health has undergone several changes over time, and with this, the need arises for health professionals to keep up to date and constantly search for knowledge. One of the main health professionals are the nurses, who are considered the main link between patients and health services and are responsible for ensuring health care(1).

In 2020, the World Health Organization (WHO), together with the Pan American Health Organization, declared it to be “the year of nurse and midwife ” , launching the “Nursing Now” campaign that foresees actions that strengthen nursing practices, including Advanced Practice Nursing (EPA), specialized nurses with specialized knowledge, capable of making complex decisions, besides specific clinical skills for the development of certain actions, thus bringing together high-performance health care, theory, practice, teaching, research and management(2,3).

There are several definitions among them, the International Council of Nurses (CIE) determines that EPA is composed of nurses who have specialized skills obtained through graduate programs, with a minimum level of Master. This profession plays a crucial role in the advancement and development of the nursing profession(4).

In order for the EPA to be able to perform effectively the CIE proposes measures that health services must adopt and these actions include providing advanced education preparation for formal recognition. It is also necessary to give the EPA a functional role integrating research, education, practice, and management, giving it a high degree of professional autonomy. Having advanced assessment, diagnostic, and decision-making skills and a certification process is important to ensure the quality of the services provided. In addition, to consolidate the EPA's action, specific legislation is fundamental that recognizes and regulates practice(5). A study in the West Pacific region presented five main areas of EPA activity, one of which was emergency care, the need for consolidation of legislation, remuneration, and strengthening of national support networks was also highlighted(6).

EPA has been present in developed countries such as the United Kingdom, the United States, and Canada since 1960, in these countries, the EPA has the function of guaranteeing and optimizing access to health services for the population, especially in vulnerable populations(1).

In Brazil, compliance with the basic principles of the Unified Health System (SUS) is one of the greatest challenges, especially compliance with the principle of universality.  Access to health has been discussed worldwide, with special attention being focused on the countries of Latin America and the Caribbean. The Pan American Health Organization (PAHO) and WHO recommend increasing the number of EPA professionals to optimize care and improve universal health coverage, thus directly improving the care provided to the population(5,7).

On July 6th, 2023, COFEN published a technical note on EPA, in which it was reinforced that there are favorable conditions to implement Advanced Nursing Practice, having leadership in post-graduate programs, a national health system with a multiprofessional team, the ability to expand access, optimizing universal coverage of the population to SUS, thus promoting better health conditions, especially for those populations living in remote, vulnerable and minority areas(8).

EPA is a fundamental part of Primary Health Care (APS), which can bring actions to improve population reach, thus optimizing universal access to health, but in the countries already in place, such as Spain, this practice has encountered several challenges. as in Brazil(9,10). Although APS is a well-defined context for the EPA in developed countries and frequently discussed in Brazil, it must be reinforced that there is still no advanced practice regulated and recognized by the regulatory and supervisory bodies of the profession. Therefore, it is important to reflect on the EPA's actions in the various practice scenarios and health care levels that extrapolate the primary care level. When talking about the other levels of health care in Brazil, we have the attention to emergencies and urgencies, in which the 24-hour Emergency Care units (24-HOUR UPA) are favorable and promising environments for applying Advanced Nursing Practices.

METHOD

This study used the methodology of reflection, which was based on literature review related to Advanced Practice Nursing (EPA), analysis of documents and legislations, and the authors' perceptions regarding the subject matter. The aim was to discuss studies in the field of nursing that focused on the topic of advanced nursing practice in 24-hour Emergency Care Units.

The authors dedicated themselves to contributing to the advancement of knowledge in this specific domain of nursing, exploring the complexities of advanced practice in continuously operating urgent and emergency environments where the speed and effectiveness of care are crucial for patient health.

RESULTS AND DISCUSSION

In Brazil, Health Care Networks (RAS) are arrangements for organizing actions and services with various complexities, which are integrated through technical, logistic, and management systems to guarantee the completeness of care. RAS is systematized with direct action in complex management and health care processes at different levels of complexity, whether in primary, secondary, or tertiary care(11).

The RAS has a focus on the population to provide a full service and continues to have health promotion as a priority. There are five thematic areas of health care, including the Urgency and Emergency Network (RUE)(11).

The Urgency and Emergency system in Brazil received broad recognition through the implementation of the Ordinance of MS 2048, of 2002, establishing guidelines for state systems, encompassing a wide network of care, from pre-hospital services, such as basic health units, family health program, specialized outpatient clinics, diagnostic and therapy services, non-hospital units, Mobile Emergency Care Service (SAMU), rescue and ambulances of the private sector, in addition to the hospital network of high complexity. Thus, the components of the care network were able to provide adequate and efficient care to urgencies and emergencies(12).

In 2011, through the Ordinance number 1600 of the MS, the National Policy of Attention to Urgencies was reformulated, where the organization of RUE has as its main objective to articulate and fully unite all levels of health care, for the purpose of expanding and improving humanized and comprehensive access for users who need urgency or emergency care. With priority being given to the lines of cardiovascular, cerebrovascular and traumatic care, aiming at guaranteeing effective and coordinated actions for the adequate treatment of patients in these critical situations(13).

RUE is composed of essential components that work together, among these components we can mention some such as SAMU and its Medical Regulation Centers, and 24-HOUR UPA, both are pre-hospital, mobile and fixed services respectively(12). 24-HOUR UPA is considered a non-hospital health unit with intermediate complexity, with the objective of establishing a network between the Basic Health Units (UBS) and the Family Health Program(PSF)with the hospital network(13).

The 24-HOUR UPA has an uninterrupted day of health services and performs the reception with risk classification, the resolute and qualified care of acute or exacerbated clinical signs, the first care to cases of a surgical nature or trauma, performs initial diagnostic investigation, medium complexity visits, and stabilization of serious cases. In addition to strengthening the rear guard of UBS and evaluating the need for referral to more complex hospital services(14).

In Brazil, the 24-HOUR UPA presents itself as a challenging scenario in SUS, mainly because it is a service characterized by overcrowding, dissatisfaction of the population seeking care in these services, low inputs and resources, patients admitted to the corridors, waiting time for care above the recommended one, overload and stress of professionals who provide care in these services, such facts bring insecurity to patients as well as to professionals, generating a great impact on public health(11). However, EPA can contribute significantly in this practice scenario to the improvement of service and assistance provided, considering the competencies and scope of expanded practice, with the application of the best scientific evidence available.  

Still in this perspective, disorganization, performance of fragmented care, misguided use of RAS, poor quality of care, unnecessary expenses, inappropriate use of resources or even scarcity of them, make it difficult to comply with the principles of SUS(14), however, they may be important indicators in the implementation of the EPA in the scenario of 24-HOUR UPA.  Precisely because it is a service with high demand, with the capacity of high complexity care, besides having highly skilled and autonomous professionals, the 24-HOUR UPA presents itself as a promising scenario for the EPA's performance.

In Brazil, there is still no implementation of advanced practices, but there are several international studies that seek to point to the contributions of the EPA(4-5,9), confirming it as a great source of knowledge and scientific practices in nursing, promoting scientific theoretical knowledge, allied to the nurse’s autonomy. This contribution of EPA can be elucidated by the role of nurses in the practice scenarios of the profession, since this is the professional who promotes the first contact of patients with the health service, being a link with the population, and of extreme importance in the whole process of health promotion, prevention and rehabilitation(4).

Nurses with advanced practice (nurse practitioner) in emergency services are indicated by international literature, such as those that provide improvements in access, reduced permanence, improvement in quality in care and increase in the level of patient satisfaction, being strategic and fundamental parts for acting in these services(15) . Furthermore, this professional should be able to have logic reasoning, complex decision-making, advanced techniques, complex clinical care, use of technologies to complement assessments, and resolution in the shortest possible time, among other aspects that locate nurses from advanced practice as a differentiated professional within the multidisciplinary team in emergency services(9).

The nurses who work in RUE are challenged daily with the high demands, the attendants that need to be faster and more precise, thus, these professionals are characterized by having an outcropped care practice, being endowed with great clinical skill, dominating health technologies, to have the spirit of leadership and the ability to make quick decisions, in addition to being the main responsible for promoting teamwork, with a collaborative vision taking care focused on the individual, but focused on the global health process(8). It is noted in the nursing practice scenario in the 24-HOUR UPA that some nurses already have specific and qualified knowledge to act in urgency and emergency situations, as well as autonomy to make decisions and work together with the multiprofessional team, skills that are in line with what is expected of the advanced practice professional(15).

With as many discussions as we critics related to 24-HOUR UPA, the EPA's action in these locations may be timely, since the complexity of care requires nurses with critical thinking for assertive decision-making, based on scientific evidence, but they also have expanded skills and competencies in health management. It should be emphasized that the urgency and emergency services in Brazil need a new organization, especially when we consider discussing regional disparities and the infrastructure of health services that are unable to absorb the entire population demand, collaborating with the dissatisfaction of individuals seeking these services.

In this discussion, the reflection on the 24-HOUR UPA as a scenario for the Advanced Practice of Nurses sheds light on three aspects that are indispensable for the assistance, namely: the need for improvements in urgency and emergency services, the need for investment and nursing valorization, and the need to improve care provided to the population. According to Püschel 2022 Brazil’s health scenarios are very favorable for EPA implementation, however, there are numerous challenges to be faced, such as: definition of the practice of the EPA professional, regulation of the actions of these professionals, consolidation of legislation and regulation by the class council, minimum structured training for EPA work, in addition to discussion of the remuneration of these professionals(1).

The implementation of EPA in Brazil is ongoing, representing a strategic decision of great importance for government policies that seek to expand the role of nurses, with the main objective of increasing the population's access to high-quality health services and professionals. The intention is to empower nurses with advanced skills and abilities, allowing them to act autonomously and focused on clinical practice, providing qualified and safe care, thus avoiding any form of negligence, imprudence or malpractice(8) .

There are evidences that the EPA provides improvements in the quality of care, increased health coverage and decreases the costs related to care, indicating that nursing care of advanced practices, when compared to medical practice, is equivalent or better. bringing improvement in the degree of satisfaction when care is provided by these nurses(16,17) . It is important to emphasize the need to expand the EPA discussion to the other SUS care levels not only in APS. There are still few evidences and discussion in the national context, about the performance of this professional mainly in the intermediate care units, such as the 24 hour UPA, locations that have great potential for action, autonomy and resoluteness for the EPA, in addition to being high-demand services with high potential for improvement.

CONCLUSION

After this reflection, it is observed that the 24-HOUR Care units are promising scenarios for the implementation of Nursing in Advanced Practice because it is an environment that requires professionals with advanced practice and skills for urgency and emergency care. Although we already have, in the context of the Brazilian urgency and emergency services, nurses who in their practice develop skills compatible with those expected from a nurse of advanced practices, there is still no discussion about the feasibility of implementing the EPA in this scenario.

This reflection advances in this sense and collaborates to expand the Nursing discussion in Advanced Practice to the other levels of attention in Brazil, since there are services with great potential to be developed, one of them being the 24-hour Care Unit. It should be emphasized that these services need to look closely at the managers, because they have been the target of several challenges, such as dissatisfaction of the population attended to, overcrowding, among others.

All the challenges presented in this reflection, have great potential for resolution with the implementation of Advanced Practice Nursing, promoting improvement in the care provided to the population, with resoluteness and political articulations within the SUS framework, aspects recommended by this specialty and that have been shown to be effective and promising results of nurses' performance of advanced practices at all health levels in the international context.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 07/14/2023

Approved: 09/27/2023