EXPERIENCE REPORT

GLOBAL PATHWAYS IN NURSING: NURSE PRACTITIONER EXCELLENCE

Beth A. Ammerman1, Andrea M. Kline2, Joseph D. Yakshich3, Deborah Lee4, Nicole Speck5, Mary Odalovich6, Jeanne-Marie R. Stacciarini7

1 University of Michigan, School of Nursing, Ann Arbor, Michigan, United States. ORCID: 0000-0001-6388-8439. E-mail: bammerma@umich.edu.

2 University of Michigan Health, C.S. Mott Children’s Hospital, Ann Arbor, Michigan, United States. ORCID: 0000-0002-3641-4200. E-mail: klineanm@med.umich.edu.

3 University of Michigan, School of Nursing, Ann Arbor, Michigan, United States. ORCID: 0000-0001-5424-0809. E-mail: jyaksich@med.umich.edu.

 4 University of Michigan, School of Nursing, Ann Arbor, Michigan, United States. ORCID: 0000-0003-2047-701X. Email: webdeb@umich.edu.

5 University of Michigan Health, C.S. Mott Children’s Hospital, Ann Arbor, Michigan, United States. ORCID: 0000-0002-0035-1180. E-mail: coli@med.umich.edu.

6 University of Michigan Health, C.S. Mott Children’s Hospital, Ann Arbor, Michigan, United States. ORCID: 0009-0003-4293-9438. E-mail: mudalovi@med.umich.edu.

7 University of Michigan, School of Nursing, Ann Arbor, Michigan, United States. ORCID: 0000-0003-0261-8413. E-mail: jeannems@umich.edu.

ABSTRACT

Objective: To describe a week-long immersion program at the University of Michigan School of Nursing (UMSN) designed to enhance Latin American nurses’ and stakeholders’ understanding of NP education, scope of practice, regulation, and leadership, supporting context-appropriate NP role development. Methods: Experience report of the “Developing Advanced Practice Nurses in Latin America” international week. An invited cohort (N=18) from six countries participated with Spanish/Portuguese simultaneous translation. Learning activities included structured presentations on MSN/DNP pathways and competencies, simulation laboratory orientation, and clinical site visits including academic medical center inpatient units, community primary care clinic, and student-run free clinic. Results: Participants observed NP autonomy in assessment, diagnosis, prescribing, care coordination, interdisciplinary collaboration, simulation’s role in competency development, and NP contributions to quality improvement, safety, and health equity initiatives across settings. Conclusion: The immersion fostered reflective dialogue on adapting United States based NP education and practice elements to various Latin American contexts. It also strengthened delegates’ intent to advocate for standardized education, supportive regulation, and expanded nursing leadership in Latin America.

Descriptors: Advanced Practice Nursing; Education, Nursing; Nurse's Role; International Educational Exchange; Leadership.

What is already known:

• Globally, more than 80 countries have Advanced Practice Registered Nurse (APRN) at various stages of development. In Latin America, only Chile has established APRN education, defined clinical roles and regulatory frameworks.

• In Brazil, Colombia, and Argentina, nurses can assume advanced clinical responsibilities despite the absence of a formal designation, standardized training, or regulatory oversight.

What this article adds:

• Details how simulation modalities facilitate competency-based education and advanced clinical judgment.

• Presents a reflective, non-prescriptive dialogue, encouraging delegates to identify elements adaptable to their local healthcare contexts, thereby strengthening advocacy and leadership.

INTRODUCTION

Advanced Practice Registered Nurses (APRNs) originated in the United States as a strategic response to the critical need for expanded access to primary healthcare, particularly among underserved and rural populations. The development of the APRN role dates back to 1965, when Drs. Loretta Ford and Henry Silver co-founded the first expanded program, training nurses to systematically assess, diagnose, and manage pediatric health issues in primary care settings(1). Since then, the scope, responsibilities, and recognition of APRNs have advanced considerably. The International Council of Nursing (ICN) has provided definitive guidance on the educational and professional standards required for APRNs to achieve global recognition and mobility. Specifically, the ICN stipulates that the attainment of a master’s degree constitutes the foundational qualification for nurses pursuing either generalist or specialist advanced clinical practice roles(2).

In the United States, the APRN Consensus Model for Regulation: Licensure, Accreditation, Certification, and Education(3) was developed in 2008 and supported by over 40 professional nursing organizations. The APRN regulatory model includes four roles: 1) Certified Registered Nurse Anesthetists (CRNAs), 2) Certified Nurse-Midwives (CNMs), 3) Clinical Nurse Specialists (CNSs), and 4) Nurse Practitioners (NPs). Each has a unique history and context but shares the APRN designation. Nurse Practitioners in both primary and acute care are trained to deliver comprehensive patient care that includes the assessment, diagnosis, and management of acute and chronic illnesses. Their scope includes performing physical exams, ordering and interpreting diagnostic tests, prescribing medications and other treatments, and making referrals. NPs also focus on health promotion, disease prevention, education, and counseling. Preparation for primary versus acute care roles involves distinct national competencies and separate certification processes, ensuring expertise in each practice area. The recognized NP specialties with board certification in the United States, under the Consensus Model(3), are Family Nurse Practitioner, Pediatric Nurse Practitioner - Primary Care, Pediatric Nurse Practitioner - Acute Care, Women’s Health Nurse Practitioner, Adult-Gerontology Nurse Practitioner - Primary Care, Adult-Gerontology Nurse Practitioner - Acute Care, and Psychiatric Mental Health Nurse Practitioner.

In practice, NPs deliver both direct and indirect patient care, with a strong emphasis on the prevention, treatment, and management of complex healthcare issues, particularly among high-risk populations. They are further required to integrate evidence-based practice, leadership, education, and clinical management into their work. The ICN also advocates for APRNs’ broad or expanded autonomy in clinical decision-making, interdisciplinary collaboration, and the authority to diagnose illnesses, prescribe medications, order diagnostic and therapeutic tests, and oversee patient admissions and discharges. These ICN recommendations collectively ensure that global APRNs are equipped to deliver high-quality, comprehensive healthcare across diverse settings(2). Systematic reviews of NP-delivered care in the United States demonstrate high-quality outcomes and significant improvements in patient length of stay, alongside reduced emergency room visits and hospital admissions(4).

The need for APRNs has been recognized globally, with an increasing number of countries establishing the role. More than 80 countries have APRN programs at various stages of development; however, specific roles, titles, education, and regulations vary significantly(5). NPs are considered the fastest-growing group of healthcare professionals globally(4). Nevertheless, the profession remains difficult to characterize on the international stage due to considerable variation in titles, responsibilities, scope of practice, and regulatory frameworks. These inconsistencies continue to shape and, at times, complicate the profession's development and recognition worldwide. Nations such as Australia, Canada, Finland, France, Ireland, Japan, New Zealand, Singapore, Sweden, and the United Kingdom have reported a formal presence of NPs within their healthcare systems(6). However, a scoping review of the literature indicated that while the United States, Canada, and the United Kingdom have consolidated regulations, regions such as Latin America, Central Europe, and Africa still face regulatory, curricular, and structural gaps(7).

The expansion of advanced practice roles in Latin America remains in its early stages. Formal recognition and regulation are largely limited to Chile, the only country in the region to have established graduate-level education, regulatory frameworks, and clinical integration(7,8). In other countries, including Brazil, Colombia, and Argentina, nurses may assume some advanced clinical responsibilities despite the absence of formal designation, standardized training, or regulatory oversight consistent with global standards(9). Persistent challenges, including uneven workforce distribution, insufficient policy advocacy, and low public awareness, continue to impede development. To realize the potential of NPs in addressing complex health needs, coordinated efforts to standardize education, enhance regulation, and elevate professional recognition are essential across Latin America.

The purpose of this article is to describe a comprehensive week-long immersion program at the University of Michigan School of Nursing (UMSN), collaboratively developed by faculty, clinicians, and graduate students for nurses and stakeholders from Latin America. The program provides both educational and experiential learning to enhance international participants' understanding of nurse practitioner education, scope of practice, and leadership in complex healthcare environments in the United States, potentially contributing to NP role development in Latin America.

METHODS

Study design

This is a descriptive report of an international immersion program titled "Developing Advanced Practice Nurses in Latin America," coordinated by the Office of Global Affairs (OGA) at the University of Michigan School of Nursing in Ann Arbor, Michigan, USA.

Setting

The University of Michigan (UM) is a public research university founded in 1817. It comprises 19 schools and colleges and more than 200 research centers, serving a student population exceeding 50,000. Historically, UM has been recognized for excellence in public research and leadership. The UMSN has been in operation since 1891, making it one of the oldest nursing schools in the United States. The school initiated its NP program in the 1970s and launched the Doctor of Nursing Practice (DNP) degree in 2008(10).

In 2015, the UMSN inaugurated a new facility featuring an expanded Clinical Learning Center with state-of-the-art simulation resources, enhancing experiential learning for Advanced Practice Registered Nurse (APRN) students. Currently, the UMSN offers specialized education in several areas: Family Nurse Practitioner (primary care), Adult-Gerontology (primary and acute care), and Pediatric Nurse Practitioner (primary care). The curriculum reflects the University’s commitment to preparing nursing leaders for advanced clinical practice, research, and healthcare innovation.

The Latin American delegation at UMSN

Latin American nurses and key stakeholders participated in an intensive, week-long immersion program at the UMSN. The program was designed to facilitate knowledge exchange and critical dialogue regarding NP education, scope of practice, and legislation within the United States. Participants engaged in direct observation, targeted experiential learning, and collaborative discourse, providing comprehensive exposure to the continuum of NP education and clinical practice. This initiative aimed to provide insights that may inform the advancement of Advanced Practice Nursing (APN) education and strengthen nursing leadership across Latin America.

Participants

The OGA maintains robust connections with various nursing organizations and academic institutions throughout Latin America. Drawing upon these partnerships, the Associate Dean for Global Health solicited recommendations from affiliated organizations to identify institutions and individuals actively engaged in advancing APN in their respective countries. Selection was by recommendation only, ensuring that participants were recognized leaders or innovators. The cohort consisted of faculty members and representatives from recognized nursing organizations.

To ensure high-quality engagement, enrollment was originally capped at 15 individuals; however, due to high demand, the inaugural cohort included 18 international visitors representing six countries: Brazil, Argentina, Paraguay, Uruguay, Chile, and Mexico. Formal invitations were extended to selected participants. The program is self-funded, with invitees responsible for travel and visa expenses; notably, the UMSN does not charge program fees, thereby reducing financial barriers to attendance.

Proficiency in English was not a prerequisite, as simultaneous translation into Portuguese and Spanish was provided for all sessions to ensure inclusivity. To foster a collaborative environment, the OGA provided meals during the immersion week, facilitating informal networking and collegiality.

Program structure: NP education, practice, regulations, and leadership

The program was strategically developed through a collaboration between the UMSN Associate Dean for Global Affairs and an NP faculty program lead. The comprehensive schedule for the "Developing Advanced Practice Nurses in Latin America" program is detailed in Table 1.

Table 1 – “Developing Advanced Practice Nurses in Latin America” program schedule. Ann Arbor, MI, United States, 2025

Note: Participants were provided with a 60- or 90-minute lunch and a half-hour ‘wrap-up’ daily.

Source: developed by the authors, 2025.

The planning process purposefully engaged a comprehensive range of stakeholders, including faculty members, practicing clinicians (specifically nurse practitioners from affiliated clinical sites), students, and senior leaders from professional nurse practitioner organizations. This one-week immersive initiative was designed to deliver an intellectually robust exploration of the advanced educational preparation, professional responsibilities, and evolving leadership and advocacy capacities that characterize the NP role. The program was implemented through an intensive sequence of structured presentations and experiential clinical site visits, providing participants with a substantive understanding of educational pathways, clinical environments, and leadership opportunities within the United States context.

The curriculum presented to the Latin American delegation included an in-depth demonstration of the Master of Science in Nursing (MSN) and DNP pathways, highlighting their intersecting elements and distinct characteristics. Central to this design are the foundational principles delineated in the American Association of Colleges of Nursing (AACN) Essentials, which articulate the core competencies and conceptual frameworks underpinning contemporary graduate-level nursing education(11). The curriculum also explored NP-specific and population-focused competencies as defined by the National Organization of Nurse Practitioner Faculties (NONPF) and the National Task Force on Quality Nurse Practitioner Education. These standards exemplify the academic rigor and advanced skill sets expected of UMSN graduates.

These academic programs consist of a comprehensive didactic component rooted in scientific and theoretical coursework, enriched by studies in patient-centered care, differential diagnosis, and the management of complex health concerns—all anchored in evidence-based practice. Complementing the classroom experience, students engage in supervised, high-quality clinical practicum hours and benefit from the integration of simulation-based pedagogies that enhance clinical reasoning and decision-making skills.

A distinctive feature of the DNP pathway discussed was the scholarly capstone project, which emphasizes the student’s development as an advanced practice nursing leader. These projects often focus on designing and implementing quality improvement initiatives or advancing health policy changes. Each DNP capstone includes an immersive residency experience, which may involve collaborating with legislators, engaging with affected populations, or implementing process improvements in clinical settings. This multifaceted approach prepares students to assume roles as transformational leaders in diverse healthcare contexts.

Furthermore, the program featured faculty-led presentations and discussions encompassing specialty areas such as pediatrics and gerontology, in both acute and primary care settings. The curriculum highlighted the intentional development of global healthcare acumen and leadership skills, reinforcing the objective of cultivating highly competent and adaptable NPs poised to address complex health challenges. A clinical preceptor provided perspectives on the progressive independence afforded to NP graduate students during clinical rotations.

The program also emphasized the critical advocacy role of NPs regarding patients, families, and the broader healthcare system. MSN and DNP students played an active role by presenting various aspects of their educational journeys, including the structure of their clinical rotations, experiences in global health, and personal development in leadership. They shared reflections on their professional autonomy and clinical decision-making. Finally, participants engaged in site visits to clinical settings where NPs are actively involved in direct patient care, enabling firsthand observation of advanced practice nursing within diverse, real-world healthcare environments.

Simulation in graduate nursing education and practice

Simulation is utilized to operationalize competency-based education, support advanced clinical judgment, and develop leadership skills. During the program, international visitors received an overview of the various simulation modalities employed at the UMSN simulation laboratory. This included a guided tour led by an instructor who detailed how diverse simulation resources enhance the education of NP students.

The UMSN graduate nursing programs employ a comprehensive range of simulation types tailored to prepare students for advanced practice, teaching, leadership, and research roles. These modalities include high-fidelity manikins and virtual environments for acute care scenarios, as well as standardized patients to support communication and diagnostic reasoning. Furthermore, the program utilizes Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs)—specially trained individuals who facilitate the practice of sensitive pelvic and prostate examinations to enhance student competence and clinical sensitivity. The curriculum is rounded out by interprofessional simulations and tabletop scenarios for collaborative practice, and Objective Structured Clinical Examinations (OSCEs) for standardized competency assessment. Each modality is strategically selected based on specific learning objectives and the competencies under development.

A central theme of the program was the distinction in complexity and focus between graduate and undergraduate simulation. While undergraduate simulations emphasize foundational knowledge, basic clinical skills, and routine patient care to build initial confidence, graduate-level simulations are designed to challenge students with advanced clinical decision-making and complex cases.

Graduate simulations frequently integrate interdisciplinary teamwork, sophisticated scenario-based problem-solving, advanced procedural training, and systems-level thinking. Furthermore, these simulations offer opportunities for students to lead quality improvement initiatives and develop expertise in teaching and specialized communication. This layered approach ensures that graduate-level simulation-based education transcends technical proficiency, fostering the critical thinking, leadership, and professional autonomy required for advanced practice roles.

Technical visits: clinical settings

This section details three site visits conducted by the international delegation: Michigan Medicine (the University of Michigan academic health center), the Packard Health Clinic (an outpatient primary care facility), and a student-run free clinic. This experiential approach allowed participants to witness the essential roles of NPs within the United States healthcare system and the implementation of innovative clinical and educational practices.

During these visits, participants toured facilities and engaged in dialogues regarding interdisciplinary teamwork, advanced clinical decision-making, and patient-centered care. A significant focus was placed on the breadth of NP prescriptive authority, providing participants with a nuanced understanding of the NP’s capacity to manage pharmacotherapy.

Michigan Medicine

Michigan Medicine is a prominent academic health center dedicated to clinical care, research, and education. The institution includes University Hospital, C.S. Mott Children’s Hospital, and Von Voigtlander Women’s Hospital, along with numerous ambulatory sites and surgical centers throughout the state. Since the recruitment of its first NP, Michigan Medicine has integrated approximately 500 NPs into diverse clinical settings. These advanced practice nurses are integral to the health system, providing comprehensive care in primary, emergency, inpatient, surgical, and critical care contexts.

The delegation visited the University of Michigan Medical Center, a facility with 1,043 licensed beds. This visit highlighted the historical evolution and contemporary diversification of the NP role in acute care. Following a formal introduction by the NP leadership team, participants met with the directors of the Neonatal Intensive Care Unit  and the Pulmonary Unit. These units were selected to demonstrate the complexity of NP practice across the lifespan—from the specialized care of premature infants to the management of complex adult conditions.

In these settings, NPs exercise a robust scope of practice that includes performing advanced physical assessments and formulating differential diagnoses, as well as developing evidence-based treatment plans and prescribing medications. Their responsibilities further encompass ordering and interpreting diagnostic studies and maintaining comprehensive documentation of patient encounters, including admissions, transfers, and discharges. Additionally, NPs collaborate closely with interprofessional teams, facilitate critical family communication, and perform specialized procedures tailored to their specific subspecialty training.

NPs also coordinate transitions of care, managing the progression of patients from acute settings to sub-acute, ambulatory, or community-based clinics. Beyond direct patient care, NPs contribute to system-level initiatives such as quality improvement, patient safety, and health policy. Notable examples include initiatives to reduce hospital-acquired infections (e.g., CAUTI, CLABSI, and sepsis) and improve mortality rates. Furthermore, NPs hold high-level administrative positions, including roles as Chief Nurse Executives and Operations Executives.

Neonatal Intensive Care Unit (NICU)

The delegation visited a 59-bed, Level IV NICU that treats more than 900 infants annually. This facility provides advanced therapies, including extracorporeal membrane oxygenation (ECMO), high-frequency ventilation, and neurocritical care. The NP team collaborates closely with the Congenital Heart Center and the Fetal Diagnosis and Treatment Center to manage complex neonatal cases and high-risk deliveries. Table 2 outlines the most common NICU diagnoses among premature infants, illustrating the clinical complexity managed by NPs in this setting.

Table 2 - Common diagnoses in the NICU. Ann Arbor, MI, United States, 2025

Source: developed by the authors, 2025.

Within the NICU, bedside Registered Nurses (RNs) and NPs fulfill distinct, complementary roles. RNs provide comprehensive care for one to two patients per shift, with responsibilities including continuous vital sign monitoring, general assessments, specimen collection, medication administration, and the management of feeding devices, drains, and ostomies. RNs are critical to patient safety, providing surveillance for clinical deterioration and notifying the provider of significant changes. They also facilitate family communication and participate in interdisciplinary care conferences.

NPs serve as the frontline providers and the primary point of contact for clinical inquiries. Their responsibilities include conducting comprehensive intakes, leading patient rounds, collaborating with neonatologists, and attending high-risk deliveries to perform life-saving interventions. NPs are authorized to order and interpret diagnostic studies, prescribe therapies, and maintain meticulous clinical documentation. Furthermore, they serve on the health system’s flight team for the transport of critically ill neonates. Interactions between the delegation and the NICU NPs highlighted the clinical autonomy and leadership essential for managing infants in highly specialized settings.

Pulmonary and Critical Care Medicine

The Medicine-Pulmonary Service Adult Care Unit admits patients requiring intermediate and intensive care, predominantly those with complex pulmonary comorbidities such as lung transplant complications, cystic fibrosis, and chronic respiratory failure.

In this unit, the delegation observed interdisciplinary rounding where NPs systematically presented patient cases. NPs serve as the principal providers for this patient group, orchestrating clinical management in close collaboration with physicians, respiratory therapists, and nursing staff. The visit underscored the NP's ability to exercise a full breadth of clinical expertise and autonomy in an acute care environment.

Packard Health Primary Care (PHPC)

This outpatient clinic serves as a safety-net provider, focusing on inclusivity for individuals facing economic, social, or cultural barriers to healthcare. PHPC utilizes a comprehensive approach to address medical, behavioral, and addiction treatment needs for all ages.

The visit was led by a Family Nurse Practitioner (FNP) who holds a dual appointment as UMSN faculty and a clinical provider, exemplifying a successful academic-clinical partnership. Participants observed how the clinic addresses the social determinants of health through an on-site food pantry, pharmacy, and laboratory, alongside programs for transportation and housing assistance. This experience demonstrated how FNPs can address multifaceted psychosocial needs to advance health equity and improve community health outcomes.

University of Michigan Student-Run Free Clinic (UMSRFC)

The UMSRFC is distinguished as one of only two safety-net clinics serving Livingston County, Michigan, providing high-quality, cost-free medical care to uninsured individuals across the broader region. As an exemplary platform for experiential learning, the clinic engages students from diverse academic disciplines in direct efforts to mitigate health disparities through hands-on service. Student coordinators assume a wide array of responsibilities, including managing patient scheduling, overseeing clinic operations, following up on diagnostic results, and facilitating referrals to essential social services. Through these pivotal roles, student volunteers navigate the complexities of caring for underserved populations while simultaneously cultivating advanced clinical, organizational, and leadership competencies.

During the Latin American delegation’s visit, the group was welcomed by a DNP student serving as the clinic administrator, who provided substantive insights into the clinic’s organizational structure and its educational impact. The delegation noted the exemplary leadership, clinical acumen, and professionalism exhibited by the students, which underscores the University of Michigan’s robust educational framework and the critical advocacy roles fulfilled by NPs in advancing equitable, high-quality healthcare. This immersive visit fostered a heightened appreciation for the capacity of family NPs and emerging nursing leaders to improve health outcomes, respond to diverse community needs, and build effective partnerships that advance health equity. The UMSRFC serves as a model for clinical education and leadership development, promoting interdisciplinary collaboration and equipping the next generation of nursing professionals to excel within complex healthcare environments.

DISCUSSION

For the Latin American nursing professionals and stakeholders, the one-week immersion program at the UMSN provided a comprehensive overview of the NP role, which remains in an incipient stage or is not yet formally established in several of their respective countries. The program offered nuanced insights into NP education, leadership development, and advocacy within the United States. Rather than presenting the United States model as universally prescriptive, the curriculum prioritized reflective discourse, encouraging participants to evaluate which elements could be contextually adapted to their local healthcare environments. This approach fostered a global exchange of ideas, emphasizing the empowerment of nurses to achieve higher standards of professional practice and leadership(12,13).

Direct observation of NP-led care models during clinical site visits highlighted the potential for NPs to address systemic gaps, such as enhancing continuity of care, mitigating physician shortages, and improving patient outcomes(12,14). These visits demonstrated the breadth of NP practice in both primary and acute care. Delegates observed NPs functioning with professional autonomy, managing complex clinical cases, and serving as patient advocates while maintaining interdisciplinary collaboration. Of particular interest was the collaborative nature of the NP-physician relationship, which emphasized integrated care rather than direct oversight. Research suggests that the dimensions of the NP practice environment—including physician and administrative relationships, role visibility, and support for independent practice—significantly influence patient outcomes(15,16).

The clinical proficiency and leadership exhibited by the UMSN-affiliated NPs resonated with the visitors, illustrating pathways for elevating nursing practice internationally. Through exchanges with clinicians, participants developed a deeper appreciation for how NPs drive quality improvement and innovation(17). This experience reinforced the imperative to advocate for expanded clinical education and the adoption of nurse-led care models customized to the distinct needs of local healthcare systems, with the ultimate goal of improving health access and universal health coverage(18).

Following the immersion program, many delegates expressed a commitment to serve as catalysts for change in their home countries. They identified opportunities to leverage their insights to advocate for policy reform, advancements in nursing education, and increased institutional support for the integration of the NP role. By envisioning these advancements, participants recognized the transformative potential of empowering nurses as leaders and advanced practitioners to improve healthcare access, equity, and outcomes on a global scale(18,19).

CONCLUSION

The international exchange provided a reciprocal learning experience for the host institution, affiliated clinical sites, and the student community. Engaging with colleagues from Latin America established essential global partnerships and expanded the collective vision for nursing education and practice. Reflecting on diverse strengths and innovations allows both host and visitor to enrich their understanding of APN and elevate global standards of leadership and service. This program underscores the transformative power of cross-cultural dialogue in shaping the future of the nursing profession.

CONFLICT OF INTERESTS

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

USE OF ARTIFICIAL INTELLIGENCE

ChatGPT was used solely to assist with grammar, clarity, and language editing during the preparation of this article. The authors reviewed and verified all AI-assisted edits and remain fully responsible for the content, accuracy, interpretation, and conclusions of the manuscript.

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Submission: 17-Mar-2026

Approved: 13-Apr-2026

Editors:

Rosimere Ferreira Santana (ORCID: 0000-0002-4593-3715)

Geilsa Soraia Cavalcanti Valente (ORCID: 0000-0003-4488-4912)

Corresponding author: Jeanne-Marie R. Stacciarini (jeannems@umich.edu)

Publisher:

Escola de Enfermagem Aurora de Afonso Costa – UFF

Rua Dr. Celestino, 74 – Centro, CEP: 24020-091 – Niterói, RJ, Brazil

Journal email: objn.cme@id.uff.br