ADVANCED PRACTICE
Positioning of entities in the field of Brazilian nursing on the expansion of the scope of practices
Livia Angeli-Silva1, Renata Corrêa de Barros2, Isabella Koster2, Elisiane Gomes Bonfim3, Jacinta de Fátima Sena da Silva1, Márcia Teles de Oliveira Gouveia3
1Associação Brasileira de Enfermagem, Brasília, DF, Brazil
2Associação Brasileira de Enfermagem de Família e Comunidade, Rio de Janeiro, RJ, Brazil
3Associação Brasileira de Obstetrizes e Enfermeiros Obstetras, Rio de Janeiro, RJ, Brazil
We, representatives of nursing entities that have actively participated in the debate on expanding the scope of nursing practice in Brazil, were surprised by the editorial, "More advances than setbacks in implementing the Advanced Nursing Practice in Brazil", published on December 22, 2023. Upon seeing our entities mentioned in that editorial, we would like to clarify the discussions and deliberations that have taken place within the Working Group on Advanced Practice Nursing in Brazil (WG–APN), established by the Brazilian Ministry of Health. Further, we express our position regarding the role of the Coordination of Superior Level Staff Improvement (CAPES) in evaluating courses focused on Advanced Practice Nursing (APN).
We emphasize that the WG-APN was initially formed to discuss APNs. However, the representatives of the institutions comprising it collectively agreed that considering the specificities and needs of the Brazilian health system, it would be more appropriate to address nursing practices. In this regard, we note divergences between this WG's objectives, discussions, and outcomes and what was mentioned in the Editorial.
Our entities have led the discussion together, intending to formulate a coherent proposal for Brazil in line with the principles and guidelines of the Brazilian Unified Health System (SUS). We also seek to value the training policies and Brazilian educational institutions that serve as examples of innovation and practice for other countries. We recognize that Brazil has made significant advances in nursing and the Unified Health System, which still need to be sufficiently considered in current international models of what constitutes APN. For this reason, we have dedicated ourselves to the debate on the population and territories' needs, taking advantage of our strengths to avoid simply importing international models. As part of this process, we published the document "Advanced Practice Nursing in Brazil: Valuing Interprofessional Work and Consistency with the Principles of the Unified Health System" in July 2023(1).
Another aspect that must be clarified is the relationship between education and regulation. By stating that while regulation in the field is advancing in Brazil, education is not keeping the same pace, the editorial reinforces the idea that the country needs to catch up with the educational processes of nurses compared to those of other countries. We emphasize that Brazil has a high level of university education in nursing, with a consolidated and advanced undergraduate program (minimum 4,000 hours) compared to other countries and postgraduate specialization, especially in residency-style training (5,760 hours of theoretical and practical training), as well as stricto sensu programs compatible with any other field of knowledge. The above statement also overlooks the problems/weaknesses in the regulation of professional practice that prevent nurses from implementing what is already provided for in the Brazilian Nursing Practice Act(2).
Also mentioned was the "convergence" of the COFEN Advanced Practice Commission "with the International Council of Nurses regarding the definition of the competencies of a Brazilian APRN to be recognized as such in the country and other contexts". Such convergence is not a consensus in Brazilian nursing since no collective process has guided and led to common decisions democratically involving the entities that have legitimately constructed guidelines for nursing education in the country, not even the educational institutions. It was precisely in response to this need for broad and collective construction that the Brazilian Ministry of Health created the WG-APN, intending to collectively consider the needs of the health system and reflect on our current educational and regulatory processes to construct a proposal for expanding the scope of nursing practice in Brazil.
Therefore, it is unfounded to blame CAPES representatives for hindering the advancement of APN training according to international standards since they supervise regular committees and groups of consultants and evaluate the quality of the reports submitted by consultants or committees. Laws with general and specific requirements that regulate postgraduate education in Brazil are internationally recognized and have a legacy to be preserved. There is no consensus proposal for nursing regarding the most appropriate training since it would make sense for our context and be recognized by other Brazilian sectors and institutions.
We emphasize that in the meetings held until December 2023, within the framework of the WG-APN, there have been studies and reflections on the training, regulation, and practice of so-called APNs in other countries, including findings on the heterogeneity of APN implementation in different settings(3-5). In addition, studies of nursing practice in Brazil have been analyzed, demonstrating the implementation of practices considered advanced in other countries in the daily routines of Brazilian nurses. As this discussion is still in its early stages, it was impossible to deliberate on the best model to adopt in Brazil. This will require further analysis in subsequent WG-APN meetings, scheduled over 12 months, with a collective output expected by the end of 2024.
In this sense, we emphasize that ABEn, ABEFACO, and ABENFO have joined efforts to generate debates and knowledge about expanding nursing practices, considering national and international contexts, but not limited to pre-established models. We reiterate our associations' commitment to Brazilian nursing, the Brazilian Unified Health System, partnerships with the Brazilian Ministries of Health and Education, and institutions internationally recognized in the scientific community, such as CAPES. We value a democratic debate that engages with international advances, always considering Brazilian needs and our achievements in education, regulation, practice, and association.
REFERENCES
1. Associação Brasileira de Enfermagem; Associação Brasileira de Enfermagem de Família e Comunidade; Federação Nacional dos Enfermeiros; Associação Brasileira de Obstetrizes e Enfermeiros Obstetras; Executiva Nacional dos Estudantes de Enfermagem. Práticas Avançadas em Enfermagem: valorização do trabalho interprofissional e coerência com o SUS. Nota de posicionamento. Brasília: ABEn, ABEFACO, FNE, ABENFO, ENEEnf; 2023 [cited 2024 feb 01]. Available from: https://www.abennacional.org.br/site/wp-content/uploads/2023/11/Praticas-Avancadas-em-Enfermagem.pdf
2. Brasil. Lei 7.498, de 25 de junho de 1986. Dispõe sobre a Regulamentação do Exercício da Enfermagem e dá outras providências [Internet]. Brasília: Ministério da Saúde; 1986 [cited 2024 feb 01]. Available from: https://www.cofen.gov.br/lei-n-749886-de-25-de-junho-de-1986/
3. Heale R, Rieck Buckley C. An international perspective of advanced practice nursing regulation. Int Nurs Rev. 2015;62(3):421-9. https://doi.org/10.1111/inr.12193
4. Parker JM, Hill MN. A review of advanced practice nursing in the United States, Canada, Australia and Hong Kong Special Administrative Region (SAR), China. Int J Nurs Sci. 2017;4(2):196–204. https://doi.org/10.1016/j.ijnss.2017.01.002
5. Yang BK, Johantgen ME, Trinkoff AM, Idzik SR, Wince J, Tomlinson C. State Nurse Practitioner Practice Regulations and U.S. Health Care Delivery Outcomes: A Systematic Review. Medical Care Research and Review. 2021;78(3):183-196. https://doi.org/10.1177/1077558719901216
6. Sousa MF de, coordinator. Práticas de Enfermagem no Contexto da Atenção Primária à Saúde (APS): estudo nacional de métodos mistos [Internet]. Brasília: Editora ECoS; 2022 [cited 2024 feb 06]. Available from: https://www.nesp.unb.br/images/pdf/relatorio_ppenf.pdf