LETTER TO THE EDITOR
The necessary debate on Advanced Nursing Practice in Brazil
Ricardo de Mattos Russo Rafael1, Sonia Acioli1, Livia Angeli Silva2
1Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2Universidade Federal da Bahia, Salvador, BA, Brazil
Understanding that the publication of a manuscript aims to disseminate thoughts on a subject exposes contradictions and constraints inherent to the investigative bias of human beings. Moreover, other elements are added to the debate by making it public. Consequently, the object, sometimes insufficient from a theoretical or methodological point of view, gains strength and takes on a new form. In the case of an editorial in a scientific journal, an additional element is incorporated as it reflects syntheses of productions, positions, and editorial policies.
In this vein, this letter aims to provide considerations regarding the editorial titled "More Progress than Setbacks in the Implementation of Advanced Nursing Practice in Brazil"(1). Far from presenting counterarguments to each point in the text, the intention here is to deepen the debate on two significant topics outlined in the editorial. In all honesty, the efforts and achievements related to Advanced Nursing Practice (ANP) in recent years are undeniable. The authors are precise in unveiling the forums for debate and regulatory advancements in this field. On the other hand, even though we have pursued a horizon in professional practice, we are still far from a theoretical consensus on this topic. One focal point for this reflection is Primary Health Care (PHC), as it has been the priority area for developing Advanced Nursing Practice (ANP) in Latin America and the Caribbean. The years of accumulation and progress in Brazilian PHC predate the discussion of ANP settling in Brazil and, consequently, require caution in incorporating international models.
The practices of prescribing medications and requesting diagnostic support exams, for example, compared to other countries, represent an expansion in the scope of practice and have been associated with Advanced Practice Nurses (APNs). On the other hand, in Brazil, these practices have been supported for decades by the professional nursing law(2) and consolidated through the PHC model established in the country. In fact, despite the importance of such shared practices with other professionals, they do not correspond to the magnitude of the actions performed during home visits, nursing consultations, risk assessment, control, and many other incredibly complex actions carried out by PHC nurses.
The manuscript "Substitution of doctors by nurses in primary care," cited in the editorial, can be translated as: "While the substitution of doctors by nurses has the potential to reduce the workload of physicians and direct healthcare costs, achieving such reductions depends on the specific care context."(3:2); Reinforcing the idea of the economic devaluation of the nursing workforce and segmented models of healthcare. Even though arguments are presented for an apparent improvement in access and healthcare quality through Advanced Nursing Practice (ANP)(4), the underlying questions in the discussion are: Is advancing the scope of Brazilian nursing practices related only to greater sharing of practices with medical professionals, aimed at reducing their workload and lowering labor costs? Wouldn't it be more opportune to use all the knowledge historically produced by nursing to consolidate and develop new practices that aim to contribute to the multi-professional team with equal recognition among professions?
Therefore, linking the scope of nursing practices in Brazilian Primary Health Care (PHC) to Advanced Practice Nursing (APN) without considering the context of the healthcare system and the nursing education model in the country can lead to the political and theoretical dilution of what ANP would represent in Brazil(5). Furthermore, if not cautious, this linkage tends to weaken decades of achievements in shaping multi-professional team models and generalist practice by reproducing an international model under the "specialization" logic - which is inconsistent with what Brazilian PHC advocates. In this case, Brazil would be regressing by attempting to specialize in what is already considered part of generalist practice.
Brazilian Primary Health Care (PHC), cited in global documents, is a reference for various healthcare systems(6). As a result, reversing the merits of progress by substituting the evolution of PHC and PHC nurses with an international strategy without due consideration is, at the very least, dangerous. Furthermore, Advanced Nursing Practice (ANP) is introduced in Brazil within the context of the international debate on universal health coverage and access, terms that are mistakenly treated as equivalent but pose significant risks to the Unified Health System (SUS).
Universal coverage is not synonymous with universal access, and Brazilian Primary Health Care (PHC), guided by the doctrinal principles of SUS (Unified Health System), operates in the unwavering defense and exercise of Universal Health Access(7). Therefore, an inadvertent importation of ANP models without the necessary cross-cultural adaptations could jeopardize nurses' genuine visibility, efficiency, and practice of years of work in Brazilian PHC. Despite the high volume of publications on ANP, there is much to build on what ANP could become in Brazil since the guidelines of the International Council of Nurses (ICN) advocate for considering the context in which practices are developed(8).
The second point being considered here is the premise that the Coordination for the Improvement of Higher Education Personnel (CAPES) denies new courses aimed at training ANPs due to a lack of accumulation regarding the regulation of this process at the national level. Although this could be a sufficient reason for not recommending the proposals, reality cannot be considered only circumstantial and limited by beliefs, as there is a risk of returning to an unresolved past after four years of attacks on this government agency.
The verbatim transcripts of a public hearing held in 2021 highlight the risks attributed to the National Postgraduate System (SNPG) when a group, thinking publicly (which is consistent with the scientific way of thinking), relied on mistaken premises to suggest changes in the evaluation system of Postgraduate Programs. The summary of this lengthy conflict was a standstill, litigation, and the creation of negative impacts on the national evaluation process(9). Currently, the SNPG is politically recovering, and caution is needed when simplifying a robust evaluation process to the beliefs and ideas of a restricted group.
The "blockage" by "not recommending" master's programs in advanced practices attributed to the coordination of the Nursing area at CAPES, in addition to questioning the position of professionals who are now seeking to regain seats on the agency's higher councils, does not consider the four criteria and approximately 40 indicators evaluated during the Application for New Course Proposals (APCN)(10). The statement in the editorial also appears not to consider a principle guiding the SNPG: the reduction of regional asymmetries in the offering of graduate programs in the country. Without a deep knowledge of the proposals examined by the judging committee and, especially, the full content of the respective opinions, it is unlikely to reach a conclusive point on the subject. It would be appropriate, therefore, to disclose their full content so that the academic community, based on these references, could better scrutinize this matter and, consequently, the statements in the editorial. This is certainly a path to be considered in future APCNs, advancing the public debate on new graduate programs stricto sensu.
Along the same lines, it does not seem fair for funding lines to guide the approval of proposals, even though funding can be an inducer of research agendas. Taking it as an inducer for the approval of new courses opens the agency to the power of capital, often dooming public institutions in various fields to frustrations, especially in times of crisis, as experienced during the critical period of Brazilian science, technology, and innovation from 2016 to 2022. Is it the desire of the scientific community for capital to dictate the areas of research training in the country? Similarly, we draw attention to the need for an analysis of the context of the healthcare system and the training system at the postgraduate level in each nation so that we do not risk importing international models that contradict the advances already consolidated in Brazil.
Therefore, the questions arise: why should the Brazilian professional master's degree program (common for all areas of knowledge), which has been in existence for over 20 years as an autonomous and sovereign program designed to train professionals for the development of research emerging from concrete reality, be modified to comply with supposed international EPA guidelines? This issue is primarily, but not exclusively, based on the different meanings that countries attribute to master's level education. This Brazilian form of education focuses on knowledge production through research, which differs from the practical workload recommended for EPA training. In other words, even though the ICN's recommendations may serve as a horizon in Brazil, they should not necessarily reconfigure a form of education that has been structured for decades.
Are we genuinely being strategic by linking EPA to the professional master's degree, disregarding other educational processes that have historically expanded the scope of practice for Brazilian nurses? Why not focus on residencies and other specializations that offer opportunities for practice in healthcare services? These political choices deserve a consistent foundation and, consequently, a deep accumulation of evidence before we define EPA as the most prominent specialized training area in the country or make a hasty judgment about those responsible for blocking a supposed advancement in the practice of Brazilian nurses.
Such accumulations are especially necessary for proposals to be approved by the area committees at CAPES, if deemed possible, and even if it was not mentioned in the editorial, by the Technical-Scientific Council for Higher Education (CTC-ES). It is important to note that the CTC-ES is a collegiate body composed of various areas within CAPES. When the area committees issue a result of APCN or quadrennial evaluation, it must be evaluated and endorsed by this instance before becoming public. In other words, it is a mistake to attribute the non-recommendation of proposals to a restricted group of individuals coordination.
As an agency of the State, the judgment carried out at CAPES, which is always imperfect and subject to public debate for improvements, is not based on individual desires. Evaluation occurs through metrics collectively constructed and widely disseminated to the scientific community. Therefore, it would be more prudent to consider that a collegiate body of about 18 areas did not recommend the approval of the programs, taking into account the opinions of the evaluation and appeals phases, and to reinterpret each of the topics pointed out by the peers (ad hoc consultants) and improve the proposals for future APCN. This is the healthy direction sought by Brazilian Graduate Studies in the context of periodic evaluations. Therefore, it does not seem fair to go beyond this discussion beyond the institutional path previously disclosed and already consolidated over decades of existence of the National Graduate Studies System (SNPG).
Not in a personalized manner. Let us have a public debate about what evaluation is and its objectives. This may be a viable and interesting direction to contribute to the system.
Invoking an old motto, those who have experienced the agency should still have it on the horizon: "CAPES is us"! Thus, disagreement is welcome and should serve as a driving force for the changes that democracy and our participatory judgment invite us to make, but always with the collective evolution of the field in mind. Sapere aude.
REFERENCES
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