Advanced Practice Nursing and the Expansion of the Role of Nurses in Primary Health Care in the Americas

Introduction

Nursing as the “backbone” of any health system is recognized worldwide (The Lancet, 2019). Currently, nurses as frontline workers are the largest group of health professionals in the world (Reynolds, 2020). Recent estimates indicate the Nursing total workforce is 27.9 million professionals, with more than 80% in countries that account for half of the world population. The Region of the Americas has 8.4 million professionals (approximately 30% of the global total), with 87% located in Brazil, Canada, and the USA, which represent approximately 57% of the region's population (WHO, 2019). However, while the Region of the Americas has an average density of 83.4 professionals, the African Region has an average density of 8.7 professionals (WHO, 2019). This inequity in the distribution of professionals persists among several different countries in the world, reflecting difficulties in access to healthcare.

Nurses have an educational background particularly suited to the growing challenges of the 21st century, characterized by an accelerated demographic transition, accompanied by a scenario of triple disease burden: 1) the unsurpassed agenda for infectious diseases; 2) the increase in deaths attributable to external causes; and 3) the predominance of chronic noncommunicable diseases (Lopes-Júnior, 2020). Advanced Practice Nurses (APN) already have their regulations well-established in many countries such as Australia, Belgium, Canada, the USA, Finland, France, Ireland, Japan, Poland, the United Kingdom, and the Czech Republic, among others (PAHO, 2018). In Latin America, especially Chile and Mexico have advanced the process of APN implementation.

Hence, a debate on the strengths and challenges for the expansion of the role of APN in primary health care in the Americas is described.

Discussion of Topic

The International Council of Nurses (ICN) defines Nurse Practitioner (NP)/APN as a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master's degree is recommended for entry level (Schober et al., 2020). Additionally, the APN role integrates research, education, care practice and management. The APN must have a high degree of professional autonomy and competence to make clinical decisions, carry out evaluations, diagnosing and prescribing, responsible for case management, evaluation and implementation of programs and plans of care, and reference for the first point of contact of users with health services (Schober et al., 2020).

The most common APN are NP and Clinical Nurse Specialist (CNS), the former having greater involvement with clinical practice and care and the latter accumulating greater responsibilities with non-clinical activities, such as education, health service management and involvement in actions to improve the quality of care, such as the development of clinical guidelines and protocols (Schober et al., 2020). Among the advanced nursing practices, the ICN included seven clinical activities: 1. Autonomy to prescribe; 2. Autonomy to request medical examinations and devices; 3. Autonomy to perform diagnosis or advanced health assessment; 4. Autonomy to indicate medical treatments; 5. Responsibility for a set of users; 6. Autonomy to refer and counter-refer users; and 7. First point of contact (ICN, 2009).

As a historical landmark of this movement, the 72nd World Health Assembly of WHO stands out, which recognized 2020 as the International Year of Nurses and Midwives, not only to honor the 200th anniversary of the birth of Florence Nightingale, the most iconic figure in the professional category, (The Lancet, 2019) but, aiming to reaffirm and make visible the daily contribution of nursing to people's health and well-being (Reynolds, 2020; The Lancet, 2019, 2020). The bicentenary of the birth of Florence Nightingale in the year 2020 elevates modern Nursing recognizing the importance of pressing and carrying out campaigns for the profession. The WHO reinforces, therefore, that nurses are fundamental to achieve and implement the Sustainable Development Goals by 2030. Among the strategies for such reach is Universal Health Coverage (UHC), so that “everyone” has access to health services (The Lancet, 2020; WHO, 2019).

However, despite its representativeness and the recognized relevance of its work, nursing remains in many aspects still invisible and undervalued, especially in health decision-making processes (Mendes et al., 2020). Indeed, nursing has historically been harms due to gender-related oppression, lack of recognition and lack of investment in resources to provide training, better conditions in the workplace and better wages (Bolina et al., 2020; Reynolds, 2020).

In this perspective, it is imperative to invest in the qualification of nurses to prepare them to deal with health problems worldwide, so that their contributions are properly understood, as well as their potential. Among the manifestations of the recognition of Nursing as a key profession for health systems and for the reach of UHC and universal access, in February 2018, the global Nursing Now Campaign (2018-2020) was launched, implemented in collaboration between ICN and WHO (Nursing Now Campaign). Nursing Now highlighted the urgent need to raise the profile of nurses and allow this profession to develop its full potential, to achieve the triple impact of Nursing on health, gender equality and the economy. In addition, the health agendas will not be successful if there are no nurses in leadership positions, in the different spaces for the definition of health policies and political decision-making for health, and that are more effective in performance of their duties (Crisp & Iro, 2018; The Lancet, 2020).

In the same year that the Nursing Now Campaign was launched, PAHO and WHO prepared the document Expanding the Role of Nurses in PHC (PAHO, 2018). which call on governments and nurses from countries in the Americas to implement APN training for PHC and Obstetric Nursing, given the potential of nurses from Central and South America, who already have specialization programs, residency, academic master’s, and doctoral degrees. This is intended to provide greater coverage and assistance to users of the health system, take advantage of nurses' intellectual capacity and retain good professionals in the profession. For PAHO, APN, in addition to contributing to health promotion, preventing disease, and reducing deaths, can take on more autonomous functions in PHC services in remote areas with vulnerabilities (PAHO, 2018).

Current Insights and Interpretations

According to PAHO/WHO, APN are professionals with postgraduate training who, integrated with the interprofessional team of PHC services, contribute to the management of the care of patients with mild acute diseases and chronic disorders diagnosed according to guidelines, protocols or clinical guides. The extended professional practice would differ from that performed by nurses in PHC due to the degree of autonomy in decision-making and the diagnosis and treatment of the patient's disorders (PAHO, 2018). Scientific evidence have showed the PHC resolutive impact on health services and on health systems costs, as well as a high user satisfaction rate (Bolina et al., 2021; Maier et al., 2016; Swan et al., 2015).

It should be noted the successful implementation of APN in PHC requires an extensive and in-depth assessment of the needs of services, the health care network, the particularities of each health system and the health needs of the country's population. It is also necessary to involve all parties that collaborate and share the practice scenario with nurses, especially physicians, but also other professional categories and users, to align expectations about professional competencies and the scope of the APN (Schober et al., 2020).

Although international experiences make it possible to identify different stages of development of the APN in several countries, research on the subject in Latin America and the Caribbean are still scarce. In this region, health needs are extremely complex and health systems have great disparities, and this is a big challenge due the high demand for communicable and non-communicable diseases, difficulties in allocating resources and the healthcare workforce, limited services coverage and quality health care (Bolina et al., 2021; Giovanella et al., 2018; Maier & Aiken, 2016).

Conclusions

Although PHC is advocated as a strategy for universal coverage, it can nevertheless have very different meanings. In the UHC agenda, PHC refers to a basic package of essential services and medicines defined in each country, corresponding to a selective approach to achieve basic universalism in developing countries. It is distinguished from the comprehensive approach of public systems with UHS where it corresponds to the base of the health system. The use of similar concepts and terms interchangeably in the PAHO/WHO document to those envisaged for UHS makes it difficult to understand the changes underway. This is a crucial moment for nursing worldwide. However, it is imperative to ensure that the voice and impact of Nursing continues to reverberate long after the end of the International Year of Nursing and Midwifery Professionals.

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