Advanced Nursing Practices: perception of graduates of the residency and professional master’s programs

Abstract

Objective

To analyze the perception of professionals who finish nursing residency or a professional master’s degree on Primary Care regarding Advanced Nursing Practices in PHC and the required training model.

Method

A descriptive, qualitative study, carried out with a workshop with six alumni graduates of the residency program in Primary Care Nursing in Family Health and two alumni graduates of the Professional Master’s Program in Primary Care in the Unified Health System, both from the Nursing School of the University of Sao Paulo. The data were submitted to discourse analysis.

Results

Empirical categories constructed were: extension of the scope of practice and autonomy for the development of the nurse’s clinical practice, decision-making based on the best scientific evidence and on the health needs of individuals and communities, professional training (professional residency, professional master’s, concurrent residency and professional master’s) and challenges for the training and implementation of Advanced Nursing Practices.

Conclusion

The empirical categories show that, in the perception of the graduates, the Advanced Nursing Practices can expand the scope and the autonomy of the nurses’ clinical practice, based on the best scientific evidence. There are also challenges for training and implementation. The articulation of residency and professional master’s is seen as one of the effective models for the training of these nurses.

Advanced practice nursing; Primary health care; Family health strategy; Graduate education; Non-medical internship

Resumo

Objetivo

Analisar a percepção de egressos da residência em enfermagem e do mestrado profissional na Atenção Básica sobre a Enfermagem de Práticas Avançadas na Atenção Primária à Saúde e o modelo de formação necessário.

Métodos

Estudo descritivo, de abordagem qualitativa, realizado a partir de uma oficina de trabalho com seis egressos da residência em enfermagem na Atenção Básica na Saúde da Família e dois egressos do Mestrado Profissional em Atenção Primária do Sistema Único de Saúde da Escola de Enfermagem da Universidade de São Paulo. Os dados foram submetidos à análise de discurso.

Resultados

As categorias empíricas construídas foram: ampliação do escopo de prática e da autonomia para o desenvolvimento da prática clínica do enfermeiro, tomada de decisões baseadas nas melhores evidências científicas e necessidades de saúde dos indivíduos e coletividades, formação profissional (residência profissional, mestrado profissional, residência e mestrado profissional concomitantes) e desafios para a formação e a implementação das Práticas Avançadas de Enfermagem.

Conclusão

As categorias empíricas evidenciam que na percepção dos egressos as Práticas Avançadas de Enfermagem podem ampliar o escopo e a autonomia da prática clínica do enfermeiro, com base nas melhores evidências científicas. Evidenciam ainda desafios para sua formação e implementação. A residência articulada ao mestrado profissional é vista como um dos modelos potentes para a formação de tais enfermeiros.

Práticas avançadas de enfermagem; Atenção primária à saúde; Estratégia saúde da família; Educação de pós-graduação; Internato não-médico

Resumen

Objetivo

Analizar la percepción de egresados de la residencia en Enfermería y de la maestría profesional en Atención Básica sobre las prácticas avanzadas de enfermería en la Atención Primaria de Salud y el modelo de formación necesario.

Métodos

Estudio descriptivo, con enfoque cualitativo, realizado a partir de un taller de trabajo con seis egresados de la residencia en enfermería en la Atención Básica en Salud de la Familia y dos egresados de la maestría profesional en la Atención Primaria del Sistema Único de Salud de la Escola de Enfermagem de la Universidad de São Paulo. Los datos fueron sometidos al análisis del discurso.

Resultados

Las categorías empíricas construidas fueron: ampliación del alcance de práctica y de la autonomía para el desarrollo de la práctica clínica del enfermero, toma de decisiones basada en las mejores evidencias científicas y necesidades de salud de los individuos y colectividades, formación profesional (residencia profesional, maestría profesional, residencia y maestría profesional en simultáneo) y desafíos para la formulación e implementación de las prácticas avanzadas de enfermería.

Conclusión

Las categorías empíricas ponen en evidencia que, bajo la percepción de los egresados, las prácticas avanzadas de enfermería pueden ampliar el alcance y la autonomía de la práctica clínica del enfermero, con base en las mejores evidencias científicas. Además, demuestran que existen desafíos para su formación e implementación. La residencia articulada con la maestría profesional es vista como un modelo importante para la formación de los enfermeros.

Prácticas avanzadas de enfermería; Atención primaria a la salud; Estrategia de salud de la família; Educación de postgrado; Internado no médico

Introduction

Discussions on the incorporation of advanced practice nurses in Brazil and Latin America began in 2013 when the Pan American Health Organization (PAHO) released the resolution Human Resources for Health: Increasing Access to Qualified Health Workers in Primary Health Care-Based Health Systems, which calls to increase the number of advanced practices nurses in Latin America, aiming to improve access to health services and achieve the goal of universal health coverage to meet the population’s health needs.¹

In 2014, the Executive Committee of PAHO proposed a Strategic Plan for Universal Health Coverage, which is focused on the quality of services and encourages the Ministries of Health of Latin American countries to train human resources to work in PHC, to introduce new professionals and technicians and to strengthen the existing ones, forming multidisciplinary and collaborative teams.²

In Brazil, the Federal Nursing Council (COFEN), in partnership with PAHO, has promoted discussions related to Advanced Nursing Practices, aiming to implement these practices in PHC. These discussions are based on the Canadian and American models and aim to increase the scope of nurses’ practice and their decisiveness, increasing the population’s health access and coverage. The profile of this professional would preferably include a nursing residency and a master’s degree.³

In a meeting held in May 2016, the Federal Nursing Council (Cofen), the Brazilian Nursing Association (ABEn), the Coordination for the Improvement of Higher Education Personnel (CAPES) and the Ministry of Health (MS) reached an agreement for the implementation of advanced practices in Brazil, with the proposal of creating a core curriculum for nurses in multi-professional and professional health residency programs, with complementation of studies to accelerate their admission to a master’s degree.⁴

The Multi-Professional and Professional Health Residency Programs have a duration of 24 months and a workload of 60 hours a week. At the end of the residency, the professionals are expected to demonstrate theoretical-practical knowledge for a safe and humanized care, based on evidence, clinical reasoning and reflective critical thinking.⁵

The Professional Master’s Degree is a stricto sensu post-graduate course that aims to provide continuing qualification for nurses and other health professionals who work in health services. It lasts up to 27 months and its objectives are to increase qualification for professional practice in health in the Unified Health System (SUS).⁶

Policies related to infrastructure, regulation of professional practice, certification, continuing education and training in undergraduate and graduate courses are fundamental aspects for the implementation of Advanced Nursing Practices in Latin America.⁷

In 2018, during the celebration of the International Nurses’ Day, experts gathered at PAHO headquarters in Washington to discuss the theme “Expanding the Role of Nurses in Primary Health Care”. The Cofen attended and presented the potential of Brazil to expand the role of nurses. It was concluded that universal access to health requires an active role of nurses in PHC.⁸

In the same year, a Cofen conference approved the study “Nursing Practices in the Context of Primary Health Care: a Mixed Methods National Study”. The objective of the study is to evaluate the actions carried out in PHC in the different regions of the country and to analyze which of them can be classified as Advanced Nursing Practices.⁹

In addition to the ongoing discussions, there are also national experiences in the development of advanced nursing practices in hospital settings. A pediatric outpatient clinic in a university hospital in Brasília and a referral hospital in pediatric oncology in São Paulo adopted work organization methodologies that incorporate skills based on the US model of clinical nurse specialist.¹⁰,¹¹

However, there are still few national studies on the subject. Thus, this study seeks to answer: What is the perception of the professionals who finish the nursing residency or the professional master’s program regarding Advanced Nursing Practices in PHC and the required training model?

Considering the actions for the incorporation of Advanced Nursing Practices in PHC and the need to explore this issue in the Brazilian context, the objective of this study was to analyze the perception of professionals who finish nursing residency or a professional master’s degree on Primary Care regarding Advanced Nursing Practices in PHC and the required training model.

Methods

This is a descriptive, qualitative study, carried out at the School of Nursing of the University of São Paulo (EEUSP), with graduates of the Residency Program in Primary Care Nursing in Family Health and of the Postgraduate Program in Professional Nursing in PHC in the Unified Health System, both of EEUSP and active in PHC.

For the study, the graduates were selected through a list available on the EEUSP website. The 15 graduates of the residency program and the 15 graduates of the master’s degree were invited to the study by telephone, e-mail and social networks. The subjects were invited to participate in a pre-established day, time and place, and were asked, if possible, to confirm their presence.

The results presented below are part of one of the methodological steps of a master’s research project with the objective of elaborating a competency profile of the advanced practice nurse in PHC.

The material presented in this article resulted from a workshop held at EEUSP, in December 2017, with authorization from the Institution and availability of the research subjects. The workshop lasted one hour and thirty minutes. It was conducted by the researcher, along with a PhD student of a research group aiming at the same topic and an observer. It was held in a room with good lighting, ventilation and chairs arranged in a circle, providing comfort and interaction between the subjects.

Initially, the proposal and the objectives of the research were presented. The participants read and signed the Consent Form (CF). The workshop schedule was shown in a PowerPoint presentation. The study subjects briefly presented themselves, mentioning their name and place of work.

Then, a discussion between the participants based on three questions began: What are Advanced Nursing Practices? Who are the advanced practice nurses? What training model is required?

After a first round of discussion, the subjects independently read an article on Advanced Nursing Practice in Latin America and the Caribbean.¹²To facilitate reading due to the short time available, the researcher highlighted the main excerpts that elucidated the definition of advanced nursing practice and how it had been developed in several countries.

After the reading, the discussion was resumed, based on the participants’ impressions on the article. In the end, the researcher presented the definitions from international and national studies addressing the subject of the training model.

The material of the workshop was transcribed and submitted to discourse analysis, as proposed by Fiorin and adapted by Carl and Bertolozzi. It consists of repeated readings of the material and decomposition of the discourse into thematic sentences.¹³After that, empirical categories referring to the perception of the subjects were elaborated. The study was submitted to the Research Ethics Committee of the Nursing School of the University of São Paulo and all the ethical precepts of research involving human beings were observed, in accordance with Resolution 510/2016 of the National Research Council (Research Ethics Committee - REC: 2.340.098 / Certificate of Presentation for Ethical Assessment - CAAE: 75455617.9.0000.5392).

Results

A total of eight nurses participated in the workshop, of which three were men. The mean age of the participants was 32 years. Only one of the members had studied in a private university, the others were from public universities. Six were attending the nursing residency and two the professional master’s program Seven participants had been in their working positions for a year, and only one had been working for more than five years. The analysis of the results allowed the elaboration of seven empirical categories, three of which are related to the perception of the subjects about advanced practice and four about the required training model (Chart 1).

Chart 1
Empirical categories on advanced nursing practices and the required training model

Advanced Practices
Extension of the scope of practice and autonomy for the development of the nurse’s clinical practice
Decision-making based on the best scientific evidence and on the health needs of individuals and communities
Challenges for the implementation of Advanced Nursing Practices
Training Model
Professional Residency
Professional Master’s
Concurrent residency and master’s
Challenges for the training in Advanced Nursing Practices

In the first category, “Extension of the scope of practice and autonomy for the development of the nurse’s clinical practice”, it was verified that all participants had previous knowledge about advanced nursing practices and that some recognized them as a way of expanding the scope of practice.

“... it is the expansion of the scope of nurses’ actions, it broadens their activities, they become more complex, through a technical-scientific improvement.”(S1)

When mentioning the extension of the scope of practice, some participants mentioned advanced practices as a possibility to also expand access to health care.

“... because you will increase access, you will provide a comprehensive care to that person, you will improve everything, and reduce the queues and all those things that appear in the media. You will increase the autonomy of the nurse, you will solve problems, because the Primary Care is very determinative, and this will make it even more.”(S6)

Advanced practices were also associated with autonomy in the professional practice and increase of its determinative character, centered on the needs of the user and the comprehensiveness of care.

“... more autonomy, it will be more determinative and you will be able to provide a better patient care, especially in this scenario and with a different qualification, which I understand will be a qualification different from the medical qualification, because these professionals will have a much broader look at the patient.” (S2)

In addition, the study subjects mentioned that in advanced practices, decision-making is based on the best scientific evidence and on the health needs of individuals and communities.

“... sufficient support for making more assertive decisions, based on scientific evidence, in their daily practice.”(S1)

“When you think about this advanced practice, it has to be for the best patient care; the focus is the patient, the focus is not me.”(S2)

“My clinical practice is what is necessary for that community. So, we are nurses who are specialists in the most common diseases in the community... so if I have to prescribe penicillin because I diagnosed syphilis, it is within my practice.” (S8)

However, they recognized that there is a set of challenges for the implementation of Advanced Nursing Practices, which are related to the development of competences, the legislation to support this professional practice and the need to overcome the doctor-centered model and move towards a comprehensive model with focus on the user and based on interprofessional work.

“... you develop new competences in the nurse, skills that he does not develop in the university... to expand the nurse’s capacity to act within several scenarios.”(S2)

“... there is still no legislation to support this. So, I believe our path will still be long.”(S6)

“... I think we have to expand our nursing diagnoses or minimally have diagnoses that are common to all health professionals, because Primary Care is done by professionals in all areas.”(S1)

As for the training model for Advanced Nursing Practices, the Professional Residency was highlighted, mainly by the insertion of the resident in the practice scenarios:

“If you [want to] join knowledge and practice, for me, this was the best model to put these things together.” (S2)

“The residency did have its barriers, but the fact is that it put me inside the service... the difference was that it made me enter a service, with the purpose of studying about it, you know? Study about my practice itself..”(S8)

As for the Professional Masters’ degree, they emphasized its importance, but presented questions about how the clinical practice would be associated with this training, which is aimed at professionals already working in health services.

“... It’s a master’s degree for people who are already working. So how are you going to include a practice workload for these people who are already working?” (S3)

“... unless the professional master’s program really has a high workload, because I understand that in order to train this professional you cannot be only here in the classroom chair, discussing.” (S2)

Some people considered concurrent residency and master as a better alternative.

“I heard of a proposal that had... I don’t know if this proposal came from MEC, that the final paper of the residency would be like a dialogue: mixing residency with the professional master.” (S6)

Regarding the challenges for training, the subjects mentioned the need to improve the relationship between theory and practice, and to include the topic since initial studies, so that advanced practices can be recognized as a possibility of professional performance.

“ The question is: whether it is a professional master’s degree or a residency, it has to have theory and practice associated and things have to be discussed.” (S1)

“ I think that this change, this movement of advanced practice will later force a change in undergraduate curriculum”. (S2)

“ I think it’s more in a diretion of having an undergraduate student who knows that this advanced practice exists.” (S8)

Thus, in the perception of these graduates, the Advanced Nursing Practices can be an innovative strategy to improve access to services and expand coverage, making it universal and based on qualified and comprehensive care provided to individuals, their families and the community. Its implementation can be done through the residency, the professional master’s degree or both, in a complementary way.

Discussion

For the graduates of the nursing residency and of the professional master’s program of EEUSP, Advanced Nursing Practices represent a possibility of expanding the scope of practice and the autonomy of the nurse. They believe that the extended clinical practice is one of the pillars for the development of Advanced Nursing Practices and propose an articulated training between the residency and the professional master’s degree.

One of the premises of Advanced Nursing Practices is increasing access to health services, by expanding the scope of actions developed by nurses, mainly in their clinical practice. However, the results of this study reinforced the need to reflect on the clinical practice of nurses in PHC and on how to broaden and qualify these actions without reproducing the biomedical model, providing “pseudomedical consultations” with an individual and curative character, or being responsible only for the organization and supervision of services.¹⁴-¹⁶

In PHC, care is based on the expanded clinic and, for this reason, it is necessary to expand care protocols, redefine administrative activities, sharing them with the health team, and work with the population to recognize the expanded role that the nurses can have in the care of individuals, families, groups and communities.¹⁷

The social construction of the extended clinical practice also occurs in the daily work of the nurse and in their relationship with other professionals, aiming to respond to the health needs of the population. Therefore, the nurses must recognize themselves as responsible for improving the quality of care and for finding spaces to consolidate their practice.¹⁶

PHC is one of the spaces that favor the development of the professional autonomy of the nurses, along with the comprehensive care of individuals, families and communities. However, in order to obtain more autonomy and broaden the scope of practice in Brazilian PHC as proposed in the advanced nursing practices, it will be necessary to overcome the hegemonic doctor-based model and to review and extend the legislation that guides nursing practice, investing in professional training, continuing education and in the development of evidence-based practices in order to respond to the population’s health needs.¹⁸

The idea of meeting health needs converges with the concept of comprehensive health, one of the principles of the SUS, characterized by a set of actions to promote, prevent and recover the health of individuals, families and the community and which should also guide the practice of the nurse who is searching for efficiency and effectiveness in their professional activity.¹⁹, ²⁰

To this end, innovative curricular proposals are required to reach professional competences aimed at the development of an autonomous clinical practice based on the best scientific evidence and comprehensive care to meet the needs of individuals, families and communities.

Regarding the training model proposed for advanced practice nurses, this study corroborated the existing literature, reinforcing the importance of the professional residency in health, the professional master’s degree and, especially, the articulation of both.¹⁸,²¹-²⁴

Health work and professional training are social practices historically articulated, with common characteristics and which still follow a predominantly uni-professional training model, based on teaching by disciplines and biomedical rationality, which is reflected in the organization of health services, resulting in predominantly medical, curative and mechanistic interventions that fragment care.²⁵,²⁶

In addition, some challenges are still to be overcome by training institutions, such as the scarcity of evidence related to advanced nursing practices in national and international literature, and, consequently, the limited insertion of the theme in the training of the students and of the teachers.²⁷

In addition, nursing undergraduate courses in Brazil have grown in a disorganized way and the nursing associations are concerned with the indiscriminate expansion and the quality with which these courses have been developed.²¹,²⁸,²⁹

In this perspective, there is much progress to be made in the development of collaborative interprofessional practice and in the debate around the expansion of the scope of practice of health professionals. Therefore, it is important to involve several social actors, including Higher Education Institutions, governmental bodies, and the associations that regulate these professions.²⁵

One of the limitations of this study was the single meeting conducted only with nurses who graduated in the EEUSP residency and in the professional master’s program, who were gathered in a workshop.

Conclusion

The empirical categories of this study show that, in the perception of graduates in the residency and professional master’s programs of the EEUSP, the Advanced Nursing Practices represent a possibility of expanding the scope of nursing practice and the autonomy of these professionals. The expanded clinical practice was considered one of the pillars for the development of Advanced Nursing Practices aimed at the providing care centered on individuals, families, social groups and communities and recognizing the health needs and the singularity of the subjects. In addition, the study revealed challenges for the implementation of and the training for these practices in Brazil. Regarding the training model, the residency, the professional master’s degree and especially the articulation between both were mentioned as alternatives for the training of these nurses.

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Publication Dates

• Publication in this collection
  29 July 2019
• Date of issue
  May-Jun 2019

History

• Received
  4 Sept 2018
• Accepted
  17 Apr 2019