More advances than setbacks in implementing the Advanced Nursing Practice in Brazil

Beatriz Rosana Gonçalves de Oliveira Toso1, Ellen Márcia Peres2

1Universidade Estadual do Oeste do Paraná, Cascavel, PR, Brazil

2Universidade Estadual do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

The year 2023 marks the first effective ten years of discussion on implementing the Advanced Nursing Practice (ANP) in the country. The first Brazilian publication on the topic dates back to 2013, addressing the practice of clinical nurses specialized in the Pediatric Oncology outpatient area(1), based on the experiences of Canadian Advanced Practice Nurses (APNs). Following this first publication, there was an editorial in Revista Brasileira de Enfermagem in 2014, already with a broader approach and dealing with the promotion of the ANP role in Latin America(2).

Also in 2014, following the knowledge presented in the Cochrane Library systematic review entitled Substitution of Doctors by Nurses in Primary Care(3), the author (BRGOT) developed a research study on ANP with nurses from England(4) during her post-PhD internship in 2014, initiating her study and research activities on the theme.

In 2015, discussions were initiated for implementing ANP in Primary Health Care (PHC) in Brazil. This involved meetings between representatives of the Federal Nursing Council (Conselho Federal de Enfermagem, COFEN) and the Brazilian Nursing Association (Associação Brasileira de Enfermagem, ABEn) at the Pan American Health Organization (PAHO/WHO – World Health Organization) headquarters; the focus of these discussions was the ANP prospects in the Brazilian context.

In 2016, the COFEN Presidency established the Advanced Nursing Practices Commission (Ordinance No. 379 dated March 11th, 2016) to support ANP development, implementation, and future evaluation in the country through research studies, in addition to producing guidelines encompassing professional training, regulation, and practice.

In August of that same year, the Professional MSc Courses in Nursing Forum (Fórum dos Mestrados Profissionais em Enfermagem, FOPRENF) held in Curitiba, PR, included a conference on the topic of ANP in its schedule. The presentation was given by the author (BRGOT), who shared her research experience in England and provided elements for discussion in the realm of training. In October, the 19th Brazilian Congress of Nursing Councils (Congresso Brasileiro dos Conselhos de Enfermagem, CBCENF) took place in Cuiabá, MT. Its schedule also included a debate panel on ANP, featuring the same author and international guests. The topic addressed in this activity was published in the Enfermagem em Foco journal(5).

Also in 2016, Nursing leaders from Latin America, including Brazil, gathered with researchers from the United States and Canada to participate in the "Advanced Practice Nursing Summit: Developing Advanced Practice Nursing Competencies in Latin America to contribute to universal health". The meeting took place at McMaster University in Canada and discussed the expansion of the Nursing practice scope in PHC and the role of APNs in different contexts.

In 2017, the Coordination for the Improvement of Higher Education Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, CAPES) included the following text in the quadrennial evaluation report for the Nursing area(6:7): ”In this context, over the past three years and in a collaborative effort with the Brazilian Nursing Association (ABEn), the Federal Nursing Council (COFEN) and regional Nursing advisory and health technicians from the Pan American Health Organization/World Health Organization (PAHO/WHO) and Latin American countries to expand universal access to health and universal health coverage, the Area has been involved in the development of policies and projects aimed at good practices, linked to the possibility of implementing the Advanced Nursing Practice in Primary Care, mainly in areas such as Family Health, Maternal, and Children's Health and Chronic Conditions, where successful initiatives already exist”.

For the first time, this report offered the possibility of discussions on the ANP training proposal in the country. It addressed the aforementioned topic that “as part of the political-pedagogical project for implementing best practices and ANP in the country, another strategy worked on by the Area in partnership with ABEn was presenting a proposal to the Ministry of Health in 2016, coordinated by PPG/UFPE, aiming to assist in identifying these projects and training the faculty so that proposals for implementing and evaluating best practices could be carried out”(6:8). Unfortunately, this proposal did not progress until 2021, when new leaders in the CAPES area coordination established a working group to resume the topic of Training, as will be discussed.

Consequently, both COFEN and ABEn, as well as other thematic events, have included the ANP topic in their schedules. Graduate courses in Nursing have taken on the theme as a discussion agenda in academic disciplines, mainly those focused on PHC. In summary, the subject matter has not left the debate panels since then and has been expanded year after year. Research studies have been developed on the theme in MSc dissertations and PhD theses. Assessment instruments for nurses' ANP competencies have been validated in Brazil(7-8) and an increasing number of Brazilian nurses are becoming familiar with or have some knowledge about ANP.

Em 2021, the CAPES area coordination created a Working Group (WG) led by the CAPES Nursing Evaluation Area Coordination (term of office from 2018 to 2022), with the participation of experts on the subject matter to discuss ANP training in the country. The results were published in the article entitled ”Advanced Practice Nursing: The 'Training' Pillar in Supporting the Proposal in Brazil”(9).

From September to November 2022, the PAHO/WHO representation body in Brazil, COFEN, and the PAHO/WHO Collaborating Center for the Development of Nursing Research at the University of São Paulo/Ribeirão Preto, organized six lecture series featuring the participation of international institutions involved in ANP development. These institutions were from Chile, Mexico, the United States, Spain, the United Kingdom, and Canada. The objective was to promote the sharing of national and international experiences, aiming to support the discussion on the implementation of ANP in Brazil.

As a result of the progress and maturation of the discussions regarding ANP in the country, in 2022 Brazilian universities submitted five proposals for APN training courses to CAPES during the opening of the Call for New Course Proposals (APCN). These proposals covered different realities, including two in the women's health area, two in the care of chronic conditions, and one in the format of an association between six universities targeted at Primary Care. In the 2022 FOPRENF held in São Paulo, the central topic was ANP, and the proposals for professional MSc training were presented and discussed.

In June 2023 and based on the CAPES evaluation results, none of the proposals was deemed suitable for ANP training by the current representatives of the Nursing area coordination. The arguments listed regarding the specificity of the proposals were different for each program submitted. However, they converged on one aspect that determined the other evaluation criteria, described as follows: ANP ”is not related to the Nursing Area scope or to exercise of the profession, as the Advanced Nursing Practice is not yet regulated in the country”.

These authors contest the assertion and argue that given that regulation is still under discussion, as mentioned below, this should not be the reason behind rejecting new training processes. For ANP to be effectively established in the country, nurses need to obtain the degree of their training at the MSc level, as recommended by the International Council of Nurses (ICN). In Brazil, the option is provided through the professional MSc model, given the minimum practice hour load of at least 500, for learning the extended clinical practice.

In 2023, COFEN updated the Advanced Practices Commission by renewing its members and issued its first Technical Note on the topic. The document, prepared by the new commission and submitted to the plenary, addresses concepts, actions, implementation, and regulation of the advanced practices that are already a reality in much of the world, including Brazil, especially in Primary Health Care (PHC)(10). Expecting more approvals for new course proposals (MSc and PhD) through the CAPES/2022 call, the Autarchy approved a six-million increase in its 2023/2024 budget to formalize the new COFEN/CAPES Agreement, to finance 100 PhD and 400 MSc vacancies, both in professional programs, including capital funds for the Programs that would be approved(10).

Also in that year, the Ministry of Health (Ministério da Saúde, MS) established a WG focused on ANP. Nursing appreciation, specialized training, and regulation of the professional practice and labor relations were topics discussed during the first meeting of the WG on ANP held in August by the MS through the Labor Management and Health Education Department (Secretaria de Gestão do Trabalho e da Educação na Saúde, SGTES) in Brasília. This meeting was the result of previous ones involving representatives from various institutions to collectively think about the possibility of expanding the scope of practices within the category and regulating the profession. SGTES/MS coordinates the WG that will propose strategies on the national theme. The group consists of departments from the following entities: MS, ABEn, COFEN, National Federation of Nurses (Federação Nacional dos Enfermeiros, FNE), Brazilian Association of Obstetricians and Obstetric Nurses (Associação Brasileira de Obstetrizes e Enfermeiros Obstetras, ABENFO), Brazilian Association of Family and Community Nursing (Associação Brasileira de Enfermagem de Família e Comunidade, ABEFACO), National Articulation of Black Nursing (Articulação Nacional da Enfermagem Negra, ANEN), CAPES, National Council for Scientific and Technological Development (CNPq), National Council of Health Secretaries (Conselho Nacional de Secretários de Saúde, CONASS) and National Council of Municipal Health Departments (Conselho Nacional de Secretarias Municipais de Saúde, CONASEMS).

In this brief report, it is evidenced that there have been many advances. COFEN renewed its Commission on the topic, showing alignment with the ICN regarding the definition of competencies for Brazilian APNs to be recognized as such, not only in the country but also in other contexts. The MS assembled a WG by joining two departments, Labor/Education and Primary Care, to discuss the regulation of the APN role. Hence, the ‘Regulation’ pillar is under construction.

Unfortunately, the ‘Training’ pillar failed to advance to the same extent. For being unaware or even disregarding the essential elements (concepts, contents, criteria), the institutional actors involved, and the recommendations made by international organizations such as ICN and PAHO/WHO, as well as national bodies like COFEN and MS, in the perspective of implementing the training programs, individuals in positions with the power to make strategic decisions in the healthcare field, with significant involvement of nurses, exert impacts on the future of the Nursing profession in the country. Without this, this cause will possibly not succeed or advance. Fortunately, the representations are periodic. Hopefully, in the future, we will have open-minded people who understand the advancement of Nursing in the country, recognizing that ANP begins with the professionals' training.

REFERENCES

1. Dias CG, Duarte AM, Ibanez ASS, Rodrigues DB, Barros DP, Soares JS, et al. Enfermeiro Clínico Especialista: um modelo de prática avançada de enfermagem em oncologia pediátrica no Brasil. Rev Esc Enferm USP. 2013;47(6):1426-30. https://doi.org/10.1590/S0080-623420130000600025

2. Cassiani SHB, Zug KE. Promovendo o papel da Prática Avançada de Enfermagem na América Latina. Rev Bras Enferm. 2014;67(5):675-6. http://dx.doi.org/10.1590/0034-7167.2014670501

3. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews. 2005;(2). https://doi.org/10.1002/14651858.cd001271.pub2

4. Toso BRGO, Filippon J, Giovanella L. Nurses’ performance on primary care in the National Health Service in England. Rev Bras Enferm. 2016;69(1):169-77. http://dx.doi.org/10.1590/0034-7167.2016690124i

5. Toso BRGO. Práticas avançadas de enfermagem em atenção primária: estratégias para implantação no Brasil. Enferm Foco. 2016;7(3/4):36-40. https://dx.doi.org/10.21675/2357-707X.2016.v7.n3/4.913

6. Ministério da Educação (BR). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior. Avaliação Quadrienal 2017 – Enfermagem [Internet]. Brasília (DF): Ministério da Educação; 2017 [cited 2023 oct. 30]. Available from: https://www.gov.br/capes/pt-br/centrais-de-conteudo/20122017-enfermagem-quadrienal-pdf

7. Minosso KC, Toso BRGO. Transcultural validation of an instrument to evaluate Advanced Nursing Practice competences in Brazil. Rev Bras Enferm. 2021;74(Suppl 6):e20210165. https://doi.org/10.1590/0034-7167-2021-0165

8. Dias FCP, Baitelo TC, Toso BRGO, Sastre-Fullana P, Oliveira-Kumakura ARS, Gasparino RC. Adaptation and validation of the Advanced Practice Nursing Competency Assessment Instrument. Rev Bras Enferm. 2022;75(5):e20210582. https://doi.org/10.1590/0034-7167-2021-0582

9. Parada CMGL, Paz EPA, Nichiata LYI, Barbosa DA, Kantorski L. Advanced Practice Nursing: “Training” Pillar in Supporting the Proposal in Brazil. Rev Bras Enferm. 2023;76(5):e20230118. https://doi.org/10.1590/0034-7167-2023-0118pt

10. Conselho Federal de Enfermagem. Nota Técnica COFEN Nº 001/2023. Nota Técnica sobre Práticas Avançadas de Enfermagem no Brasil (PAE): contexto; conceitos; ações empreendidas, implementação e regulação [Internet]. Brasília (DF): Cofen; 2023 [cited 2023 oct. 30]. Available from: https://www.cofen.gov.br/nota-tecnica-cofen-no-001-2023/