Background

Brazil is a country with continental dimensions that is subdivided into five geographic macroregions (North, Northeast, Midwest, Southeast, and South) with different demographic and socioeconomic conditions and wide internal inequalities [1]. The Brazilian Unified Health System (SUS), that is oriented toward primary healthcare (PHC), suffers from a shortage, high turnover, and unequal distribution of physicians [2, 3], especially in the rural and remote areas of the Northern and Northeastern macroregions. This threatens the population's access to high-quality, definitive care [4, 5]. Approximately 20,000 doctors graduate annually in Brazil, and they are mostly incorporated into private healthcare services in large urban centers [5,6,7]. Meanwhile, there is a growing number of nurses in the labor market (40,000/year), with greater availability to work in the public healthcare sector, whose services could be more efficiently utilized [6, 7]. New profiles such as the advanced practice nurse (APN) may be instrumental in advancing Brazilian PHC and achieving universal healthcare coverage [8].

The APN has specialized knowledge, complex decision-making skills, and clinical skills for a broader scope of practice, and their characteristics are shaped by the context in which they are certified to practice [9,10,11,12]. In PHC, the APN operates with an expanded scope of practice that incorporates the physician’s tasks and involves either substituting or complementing the physician’s work [9]. In the United States and Canada, advanced practices include diagnosing and treating acute and chronic diseases, ordering and interpreting diagnostic tests, prescribing drugs without a physician’s supervision, and referring patients to specialists [9, 13, 14]. Mirroring the experiences of these countries, Brazil is investigating the possibility of introducing the APN into primary care [15].

Given the incipience of national studies that are oriented toward the implementation of the APN in the SUS, this study analyzes the practices of Brazilian nurses based on three components—regulation, practice, and education—to identify and compare the nature of authorized practices, practices developed in PHC, and practices taught in undergraduate nursing programs.

Methods

We conducted a national multi-method study that triangulated primary and secondary data, in order to analyze the problems, conditions, and opportunities involved in introducing APN in Brazil. For the regulation component, we analyzed a set of official normative documents that detail the regulation of nursing education and the nurse’s scope of practice in the context of PHC. We retrieved these documents in March 2021 from the websites of the Ministries of Health and Education and the Federal Nursing Council (COFEN)Footnote 1 and conducted a qualitative analysis of their content.

For the practice component, we performed a scoping review [16] of primary studies conducted on nurses practicing in PHC in Brazil to identify the practices effectively performed by these professionals. In March 2021, we used a standard search strategy to consult different scientific databases, and 22 of the 780 studies found were selected for analysis. This set of studies included 3618 PHC nurses and described more than 90 activities performed in daily professional practice (More information can be found in Additional File 1). We presented the results of the review in the form of a narrative synthesis.

We examined the education component based on a national exploratory study that conducted telephone surveys and face-to-face interviews with directors of undergraduate nursing programs; some of these data have been previously published [17,18,19]. In this study, we assessed the data that revealed the specific practices that nursing programs had taught their students. The telephone surveys were conducted with 94 directors in the first semester of 2016, after a sample calculation based on the total number of programs in 2013 [17]. We used descriptive statistics to analyze the data. Between November 2015 and March 2017, face-to-face interviews were conducted with 16 directors who did not participate in the telephone survey [18]. The interviews were recorded, transcribed, and submitted for content analysis. All ethical aspects were observed in accordance with Brazilian legislation.

Triangulation involved fusing the data sets for each stage, synthesizing the results in an explanatory structure, and generating a final discussion. During triangulation, inferences and recommendations were extracted from the findings of the combined results for a better understanding of the phenomenon in question [20].

Results

Regulation

In Brazil, the Federal Government has exclusive legislative power over professions and has the power and duty to supervise the activities of professions. As state-controlled entities, healthcare professions are regulated by three branches: the legislative branch creates laws for professional practice, the executive branch provides curricula and implements health policies, and the judiciary branch makes decisions in the context of legal disputes. Another important source of regulation is the professional councils, which are federal autarchies, as recognized and authorized by the State, that have the power to supervise and discipline professional practice [21].

Nursing is one of the 24 healthcare professions currently under regulation in Brazil, and the right to exercise this profession is guaranteed by Law No. 7.498/1986 [22], which establishes that nursing can only be practiced by nurses, nursing technicians, nursing assistants, and midwives. It also stipulates that nursing activities can only be performed by persons who are legally qualified and registered with the regional professional council that has jurisdiction in the state where they practice. For nurses, this qualification is granted through a bachelor's degree issued by an institution certified by the Ministry of Education

Nurses’ educational preparation must follow federal guidelines that specify training should prepare students to become professionals with a generalist profile who can cope with the main health problems of the nation [23]. Given the specificities of the SUS, training should include developing skills that apply in different healthcare services, particularly those required by PHC (Table 1).

Table 1 Educational guidelines for the Bachelor’s in Nursing degree in Brazil
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According to Law 7.498/1986 [22], the nurse is responsible to perform all nursing activities, while managerial practices and activities of greater clinical complexity are exclusive to them. With the exception of these exclusive activities, this legal provision does not detail the actions included within the nurse’s scope of practice. This may be because part of a nurse’s functions has been historically legitimized, as it is one of the first healthcare professions to be regulated in Brazil. Meanwhile, many practices, usually reserved for nurses, have been incorporated by other professions (such as nutrition and psychology), thus resulting in a need to review nurses' attributions.

This dynamic is permanent in the world of healthcare professions, largely in part because professional councils have normative and regulatory competence that allows them to define the activities that can be performed by their professionals [21]. Between 1975 and 2020, COFEN published more than 300 provisions that ensure, authorize, or prohibit practices. These provisions often trigger jurisdictional disputes over particular or exclusive acts, especially in regard to medicine, which has solid ties with parliamentary leaders and constantly attempts to restrict other professions’ scope of practice to preserve its exclusive practice areas.

In the context of PHC, nursing activities must take into account the epidemiological aspects and guidelines for the healthcare practices set forth in Law 7.498/1986 [22] and in the Brazilian primary care policy [24] that describes the general duties of those who comprise the multiprofessional healthcare teams. More detailed functions are contained in guidelines, manuals, and thematic journals that specify care for particular groups (e.g., women's health, children's health, chronic diseases) and are updated periodically based on new evidence. From this perspective, nurses have legal prerogatives for expanded assistance in Brazil: in PHC, they can request complementary tests, prescribe medication, and refer patients to other professionals and services. However, in the local context, municipalities define the scope of this assistance based on technical norms or specific nursing protocols.

Table 2 presents a summary of the set of authorized practices for Brazilian nurses.

Table 2 Synthesis of the set of permitted and prohibited practices for Brazilian nurses based on legal provisions
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Practice

The practices performed by nurses in PHC can be divided into four interdependent dimensions: clinical, managerial, health surveillance, and educational. The investigative dimension was not evidenced in the literature (Fig. 1).

Fig. 1
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Dimensions of practices performed by Brazilian nurses in primary healthcare

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The managerial dimension mainly includes the practices of organizing, planning, and supervising the actions of technicians, assistants, and community agents; holding and participating in meetings; and setting agendas. In general, nurses are also the managers of the health units, and this dimension occupies a large portion of the nurses' working time, reinforcing the idea that much of what nurses do is invisible [25,26,27,28,29,30,31].

The purpose of health surveillance is to constantly observe and analyze the population's health status to control health determinants, risks, and harm. This dimension includes actions to promote, prevent, and control illnesses and vulnerabilities over the area of operation, such as active searches, notification of events in public health interest, and vaccination campaigns [26,27,28,29,30,31,32,33]. The educational dimension, which is part of the other dimensions, encompasses health education actions for individuals, families, and groups; permanent education for other team professionals; and student mentorship [25,26,27,28,29,30,31,32,33,34,35].

Clinical practices—care provided directly to the user—are most performed by nurses and occur mainly in the context of spontaneous demand and nursing consultations, either in the unit or during home visits. Nursing consultations constitute a strategy that favors performing the actions prescribed in programs that integrate PHC. Moreover, these actions are the main reasons why nurses provide care, such as management of chronic non-communicable diseases, sexual and reproductive health, women’s health, and prenatal care [25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44]. In this dimension, the most common technical procedures include the administration of vaccines and medications, the collection of oncotic colpocytology (Pap smear) and test materials, and the application of dressings and glucose tests. The most common prescriptions are for dressings, and—according to clinical protocols—for medication, supplements, and laboratory tests, especially within prenatal care and diabetes and hypertension management [27,28,29,30, 35, 36, 39,40,41,42,43,44,45,46].

A study [40] conducted on more than 2500 nurses working in PHC found that these nurses knew how to perform more activities in addition to those that they carried out in their workplace. The reasons for their limited work practice were the lack of municipal clinical protocols and/or the existence of restrictive measures by the professional council. The nurses who performed exclusive medical activities—abscess drainage (30%), sutures (5%), and local anesthesia (6%)—did so either because there was a lack of doctors in the units or because the doctors did not have the technical skills to perform them [29, 39, 40].

Education

In terms of the practices taught in undergraduate nursing programs, we determined that students are prepared to carry out various actions that are legally and socially recognized as nurse’s activities. Meanwhile, the practices that nurses are allowed to perform, but are historically understood to be the physician’s responsibility, were mostly classified as capacities that were not covered or only partially covered by programs (Table 3). In face-to-face interviews, the evaluation of the last set of actions, especially prescribing medication, was preceded by justifications based on the perception that these functions go beyond the nurse’s scope of practice.

“We do not teach how to prescribe any medication, not even those provided for in the protocols. It falls under the physician’s responsibility [...]. The nurse performs diagnostic tests because it is technical, but interpreting and making diagnoses does not fall under the nurse’s responsibility either.” (Southern macroregion)

“There is the issue of primary care protocols that dictate what nurses can do. But, seriously, the nurse has to do what a nurse has to do. We cannot be concerned with what the other person does. There is no point in wanting to prescribe medication if one does not even know how to make a nursing diagnosis.” (Southeastern macroregion)

Table 3 Percentage of nursing programs according to the preparation of students for the development of actions (n = 110)
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Moreover, we found that students are not prepared to perform exclusive medical activities. Nevertheless, directors recognized that during educational internships, students accompany nurses who performed such activities, especially in rural areas.

"In the countryside, many nurses perform medical actions in the absence of a physician." (Midwestern macroregion)

“My students accompany nurses who prescribe medication, apply sutures. And they will surely have to perform these procedures out of necessity after they graduate. Will they see a person with tuberculosis or pneumonia and, knowing the appropriate medication, not prescribe it, because it is not within their responsibility? Can I characterize that as what, neglect?” (Northern macroregion)

Discussion and conclusion

The process of introducing APN in Brazil remains in the initial stages of discussion. In addition, the first studies on the subject remain in the early stages of development, the results of which may define the APN model for implementation. Jhpiego [47] proposes initiating the operationalization of the model by defining its scope of practice, which includes describing the professional’s activities, responsibilities, and level of authority based on a situational analysis of the demands of the healthcare system. Subsequently, the skills required for safe, effective practice and the policies that ensure professional autonomy must be defined.

In Brazilian PHC, common illnesses, which are generally benign, self-limiting, and minor, and social illnesses, occur more frequently in a community. Despite this plurality, demand is concentrated on a few problems or reasons for consultation [48], the most frequent being chronic diseases, especially non-insulin-dependent diabetes and uncomplicated arterial hypertension; family planning; prenatal care; and health maintenance/disease prevention [48,49,50,51]. These demands require developing nursing actions that align with the skill set in the curricular guidelines and are anchored in the scope of practice authorized by the legislation and primary care programs guidelines.

This study demonstrates that these demands correspond with the main reasons for the nurse’s care in PHC. They perform a set of clinical, managerial, educational, and health surveillance activities, including advanced practices, according to international models [10,11,12]. Although to a lesser extent, nurses also perform exclusive medical practices in the absence of a physician in health units. Furthermore, this study indicates that most undergraduate programs do not fully prepare students to adequately execute advanced tasks. These results corroborate with the findings of other studies conducted on the nursing field [40, 52].

This gap in the training process can be attributed to several factors, such as: (a) the lack of articulation between educational institutions and health services, resulting in curricula that do not correspond to the training demands required by the health context [17, 18]; (b) although extensive, the workload of bachelor's degree courses is insufficient to promote the development of all the skills required by the health system [18, 53]; (c) advanced practice nursing is a little explored and controversial subject in Brazil. The implementation of these practices is not unanimous among nurses, and it is poorly understood by other professionals, health managers, nursing professors and SUS users [19, 54]; (d) the training regulations are generic, allowing different interpretations, and are obsolete, as they no longer reflect the social and health needs of Brazil [18, 53]; (e) some nurses and nursing professors believe that the profession has distanced itself from its real attributions in the care process, and it is not up to them to incorporate other activities [19]; (f) the bachelor's degree courses in nursing are mostly private (90%), whose teaching has been characterized by the precariousness of practical activities. In this aspect, there is a differentiated training in public and private schools that neither serve the interests of the profession nor the training of professionals for the SUS [53].

Although it is verified that there has been an increase in nurses' autonomy within the PHC over the last decades, notably due to the expansion of their clinical performance supported by legal documents, their work is still technically subordinate to that of the physician and is thus socially understood [55]. This finding reaffirms that the training model is still centered on clinical specialties and guided by the logic of "professional tribalism”,Footnote 2 as opposed to the logic of training and work in PHC, which is based on health needs population, interdisciplinarity and professional collaboration [56, 57]. All these factors, to a lesser or greater degree, are reflected in the curricula and pedagogical practices of bachelor's degree in nursing.

Despite this, advanced practices seem to already be occurring in Brazil. There are national documents that ensure and authorize nursing graduates to conduct these practices, thus rendering the municipalities to prepare the appropriate clinical guidelines for local needs. The guidelines must comply with the legal and ethical principles of the profession and SUS rules and regulations, consider the best available evidence, and enable professional autonomy. Furthermore, once deficiencies in the training process have been verified, the current education model should undergo reforms to incorporate the skills compatible with the regulated advanced practices. There is already a need to expand the curricular contents of pharmacology, pathophysiology, and evidence-based practice [52, 58].

Immediately, additional training through interprofessional continuing education processes is recommended for professionals who already work in PHC, to ensure the quality of care and the professional's safety in their performance of advanced practices. It is also imperative to update the normative acts that regulate education and the scope of practice, as they are outdated and too general in terms of describing the skills and the scope of advanced practices (Table 4).

Table 4 Convergent matrix of the research results
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If Brazil decides to introduce the international APN model, either by safeguarding current advanced practices or by expanding them, the process would be more arduous and time-consuming. It would require reforming the current model of professional regulation in order to comply with the countless recommendations that sustain APN characteristics, such as additional educational preparation in certified programs at the professional master's degree level, protected titles, and specific APN regulations [8, 12]. Figure 2 proposes the steps to operationalize this APN model.

Fig. 2
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Steps and recommendations for operationalizing the Brazilian advanced practice nurse model

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Unlike international recommendations, we do not believe that the professional master's degree is the most appropriate level of training in the Brazilian context. These programs are found mostly in large urban centers and are strongly influenced by academic models that contrast with the proposal to train nurses in the exercise of professional, transformative practice [59]. We suggest seeking additional training in lato sensu graduate programs,Footnote 3 especially in interprofessional family medicine residency programs.

Regardless of the adoption of the APN model, other future objectives in Brazil include fortifying education and interprofessional work and permanent education actions, wage reform, investment in infrastructure and working conditions, and greater control over the formation and quality of undergraduate programs. Moreover, a greater governmental role is necessary in the regulation of healthcare professions, specifically to mitigate weaknesses of laws on the exercise of professions and to resolve corporate clashes over disputes regarding scope of practice [60].

Expanded, fluid, and flexible regulatory legislation could be defined based on inter-professionalism and task sharing, thus establishing common goals for all healthcare professions and specific regulations for a given profession. This model could provide flexibility in the division of healthcare work by adopting public interest as its guiding principle, rather than the profession’s organizations, its self-regulation, or the monopoly imposed by professional categories.