https://doi.org/10.31011/reaid-2023-v.97-n.3-art.1811

¹Ernanda Mezaroba

²Bárbara Rodrigues Araujo

³Beatriz Rosana Gonçalves de Oliveira Toso

⁴Rita Catalina Aquino Caregnato

⁵Lisiane Manganelli Girardi Paskulin

⁶Andrea Wander Bonamigo

¹Enfermeira. Doutoranda em Enfermagem pelo Programa de Pós-Graduação da Universidade Federal do Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brasil. ORCID ID: 0000-0002-1603-0330.

²Enfermeira. Graduada pela Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brasil. ORCID ID: 0000-0002-6508-6955.

³Enfermeira. Doutora em Ciências pelo Programa de Pós-graduação em Enfermagem em Saúde Pública da Universidade de São Paulo. Professora Associada da Universidade Estadual do Oeste do Paraná. Cascavel, Paraná, Brasil. ORCID ID: 0000-0001-7366-077X.

⁴Enfermeira. Doutora em Educação pela Universidade Federal do Rio Grande do Sul. Professora Associada II, do Departamento de Enfermagem da Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brasil. ORCID ID: 0000-0001-7929-7676.

⁵Enfermeira. Doutora em Ciências pela Universidade Federal de São Paulo. Professora Associada da Universidade Federal do Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brasil. ORCID ID: 0000-0003-1444-4086.

⁶Fonoaudióloga. Doutora em Saúde Pública pela Universidade de São Paulo. Professora na Universidade Federal de Ciências da Saúde de Porto Alegre. Porto Alegre, Rio Grande do Sul, Brasil. ORCID ID: 0000-0001-6435-704X.

Corresponding author

Ernanda Mezaroba

Avenida Paulo Gama, 110. Porto Alegre, Rio Grande do Sul, Brazil, CEP: 90040-060. contact: +5551 982599326. E-mail: emezaroba@gmail.com

Submission: 19-04-2023

Approval: 30-08-2023

ABSTRACT

Aim: to analyze the potentialities and observers for the implementation of Advanced Nursing Practice in Primary Health Care. Methods: cross-sectional, exploratory and descriptive study. The population consisted of 33 nurses linked to the Health Department of a municipality in the south of the country. Data were collected through protection in October and November 2019. Data analysis was by descriptive statistics. Results: the practice guided by protocols with scientific evidence, the use of the full potential of the nurse and the increase in problem-solving ability stood out as potentialities. The most cited were bureaucratic and administrative activities, learned from human resources and the possibility of conflicts with the medical area. Conclusions: more potentialities were evidenced than the hosts. Thus, the implementation of advanced nursing practice in primary health care emerged in this study as a potential action that, through training guided by the health care model, emerges as a strategy to provide better health outcomes for the Brazilian population. The study brings benefits to support the implementation of a widespread practice in countries that have already been carried out, which can bring benefits to the Brazilian health system.

Keywords: Delivery of Health Care; Primary Health Care; Advanced Practice Nursing; Public Health.

RESUMEN

Objetivo: analizar las fortalezas y debilidades para la implementación de la Práctica Avanzada de Enfermería en la Atención Primaria de Salud. Métodos: estudio transversal, exploratorio y descriptivo. La población estuvo conformada por 33 enfermeras vinculadas al Departamento de Salud de un municipio del sur del país. Los datos se recolectaron a través de un cuestionario estructurado en octubre y noviembre de 2019. El análisis de datos se realizó mediante estadística descriptiva. Resultados: se destacaron como potencialidades la práctica guiada por protocolos con evidencia científica, el aprovechamiento de todas las potencialidades del enfermero y el aumento de la capacidad de resolución de problemas. Las debilidades más citadas fueron las actividades burocráticas y administrativas, la insuficiencia de recursos humanos y la posibilidad de conflictos con el campo médico. Conclusiones: se destacaron más fortalezas que debilidades. Así, la implementación de la práctica avanzada de enfermería en la atención primaria de salud surgió en este estudio como una acción potencial que, a través de la formación alineada con el modelo de atención a la salud, surge como una estrategia para proporcionar mejores resultados de salud para la población brasileña. El estudio trae subsidios para apoyar la implementación de una práctica difundida en los países desarrollados, que puede traer beneficios para el sistema de salud brasileño.

Palabras clave: Atención de la Salud; Atención Primaria de Salud; Enfermería de Práctica Avanzada; Salud Pública

RESUMO

Objetivo: analisar as potencialidades e fragilidades para a implementação da Prática Avançada de Enfermagem na Atenção Primária à Saúde. Métodos: estudo transversal, exploratório e descritivo. A população foi de 33 enfermeiros vinculados à Secretaria da Saúde de um município do Sul do país. Os dados foram coletados através de questionário estruturado em outubro e novembro de 2019. A análise dos dados foi por estatística descritiva. Resultados: sobrelevaram-se como potencialidades a prática norteada por protocolos com evidências científicas, o aproveitamento do pleno potencial do enfermeiro e o aumento da resolutividade. As fragilidades mais citadas foram atividades burocráticas e administrativas, insuficiência de recursos humanos e possibilidade de conflitos com a área médica. Conclusões: foram evidenciadas mais potencialidades do que fragilidades. Assim, a implementação da prática avançada de enfermagem na atenção primária à saúde emergiu neste estudo como uma ação potencial que, por meio de formação alinhada com o modelo de atenção em saúde, surge como uma estratégia para proporcionar melhores resultados de saúde à população brasileira. O estudo traz subsídios para apoiar a implementação de uma prática bastante difundida em países desenvolvidos, que pode trazer benefícios para o sistema de saúde brasileiro.

Palavras-chave: Atenção à Saúde; Atenção Primária à Saúde; Enfermagem; Prática Avançada de Enfermagem; Saúde Pública.

INTRODUCTION

Advanced Nursing Practice (ANP) emerges as a possibility of innovation and advancement for Brazilian public health given the growing interest in assuming care capable of bringing improvements to health systems, meeting the needs of the population^(1,2). An Advanced Practice Nurse (EPA) is a professional with specialized knowledge who must have complex decision-making skills and clinical skills for expanded practice. These skills are formally developed through recognized educational preparation for this role, preferably at the master's level, with characteristics determined according to the implementation policy of this practice in each country⁽³⁾.

PAE involves research, education, care practice and management, requiring nurses to have autonomy, knowledge for assessment, diagnosis and prescriptions. It also involves case management, the implementation of programs and assistance plans, in addition to understanding that this professional must be a reference for the first contact between users and health services⁽³⁾. Therefore, the PAE enables the qualification of preventive, promotional, treatment and rehabilitation nursing practices in various health care services⁽²⁾.

In countries where PAE is implemented, such as the United States and Canada, the EPA's roles began informally due to the need to improve access to health services, through the development of additional skills and the expansion of the scope of its practices through experience⁽⁴⁾.Recently, with a view to meeting the health needs of the population, the Member States of the Pan American Health Organization (PAHO) approved Resolution CD52.R13, which supports autonomy for multidisciplinary teams that work in health care. Primary Health Care (PHC) and supports established care models, citing the expansion of nurses' roles in Latin America and the Caribbean through the proposal of advanced practices⁽⁵⁾.

The implementation of PAE in PHC in the Brazilian context is justified by situations experienced in the current context, highlighting: the shortage of doctors; the inadequate distribution of health professionals, given that urban areas with more economic resources attract the majority of these professionals; and, limited skills and autonomy to provide quality healthcare. In this sense, it is considered that PAE can significantly contribute to the development and good functioning of health systems in Latin America and the Caribbean ⁽⁶⁾.

In Brazil, discussions about PAE gained ground from 2015 onwards, with three events standing out: the establishment of the Commission for Advanced Nursing Practices (CPAE) by the Federal Nursing Council (COFEN)⁽⁷⁾the publication by PAHO of the document “Expanding the role of nurses in primary health care”,⁽⁶⁾with information relevant to Latin American and Caribbean countries for incorporating the EAP; and the development of the research “Nursing Practices in the Context of Primary Health Care”,⁽⁷⁾ which was recently completed and aims to carry out a situational diagnosis in the country in relation to the nursing practices performed by nurses. This research was developed by COFEN and the University of Brasília, in partnership with CONASS (National Council of Health Secretaries), CONASEMS (National Council of Municipal Health Secretaries), ABEFACO (Brazilian Association of Family and Community Nursing) and PAHO.

In view of the continuous transformations of innovations and discussions on the subject, the interest in expanding nurses' professional skills and abilities in convergence with the incentive regarding the implementation of the PAE is well known in the country. However, little is known about what nurses think about the implementation of EAP. Thus, a study of an exploratory and descriptive nature, identifying variables that may favor or hinder the implementation of EAP, may support discussions about advanced practice with nurses working in PHC, managers and professional councils. To understand this gap, the objective of the study was: to analyze the potentialities and weaknesses for the implementation of PAE in PHC.

METHODS

Cross-sectional, exploratory and descriptive study. The research participants were nurses linked to the Municipal Health Department of a city in the south of the country, covering professionals from the management team, epidemiological surveillance and PHC network services. The choice of location and professionals is related to the main researcher's formal employment relationship and the fact that the municipality has dedicated itself to qualifying PHC by expanding nurses' clinical practice.

33 nurses linked to the Municipal Health Department during the data collection period were included in the study. Professionals who were away from work for reasons such as sick leave or other reasons during the data collection period were excluded.

Data collection took place between October and November 2019, using a structured, closed questionnaire, with nine objective questions (seven with a single answer and two with multiple answers), self-administered. The questionnaire was prepared by the authors based on an in-depth literature review in the Scientific Electronic Library Online (Scielo) and gray literature on the web using the descriptors: Advanced Nursing Practice and Primary Health Care. 36 articles and 16 publications involving guidelines were identified, reports, legislation and other documents, which made up the corpus of analysis. The material was searched for elements that could make up the strengths and weaknesses of the PAE. Based on these criteria, the research instrument was constructed. The questionnaire provided an introduction to the topic, addressing factors that permeated the trajectory of PAE in the countries in which it is consolidated and a brief description of aspects related to this practice. The questions were organized into two parts. The first part included the characterization of the study participants, covering the variables: age, gender, length of experience in PHC, form of hiring, academic training (maximum degree) and role currently held; and the second part included information about the PAE: training/professional performance to develop the PAE and potentialities and weaknesses for its implementation in PHC, defined based on the literature review.

Regarding the question about professional training/performance, we sought to identify whether nurses considered their experience and professional trajectory adequate to develop EAP. The following alternatives were made possible: sufficient; partially sufficient; insufficient, with the possibility of justifying the answers. Regarding potential, the answer options were: ease of access to the health service; taking advantage of nurses’ full potential; strengthening bonds with patients; performance of health care previously performed by a doctor; adoption of guided practices supported by protocols with scientific evidence; humanization of nursing care; possibility of achieving a more respected professional status; cost savings for the health service; organization of the nurse's work process; possibility of promoting teamwork; qualification of nursing care; increased resolution; user satisfaction with the health care provided; other(s), enabling the research participant to describe additional aspects that they considered potential.

Regarding weaknesses, the response options were: execution of bureaucratic and administrative activities; performance of health care previously performed by a doctor; insufficient human resources in health services; organization of the nurse's work process; other(s), also allowing the inclusion of some other item.

For data collection, a first contact was made with the nurses during a team meeting, in which an explanation about PAE was given, and the research proposal was presented. The activity lasted approximately 60 minutes and allowed clarification of doubts and discussions. Afterwards, a formal invitation to participate in the study was made and, after acceptance, the nurses were instructed to sign the Informed Consent Form. The printed questionnaire was then delivered to them, agreeing on a seven-day deadline for returning the completed instrument. To collect the questionnaires at the study participants' workplaces, a second contact was made between the researcher and the research participants.

The collected data were entered into electronic spreadsheets in the Microsoft Excel program, after being processed and analyzed by the Statistical Package for Social Science Program (Version 22.0), using descriptive statistics. The absolute frequency and percentage for the categorical variables were obtained. The study received approval from the Research Ethics Committee under opinion number 16425619.7.0000.5345 and met the criteria required for research involving human beings.

RESULTS

The characterization of the participating nurses is presented in Table 1.

In relation to the potential, mentioned by more than 70% of the participants, the following items stand out: Practice guided and supported by protocols with scientific evidence (97%); Taking advantage of nurses’ full potential (90.9%); Increased resolution (90.9%); Qualification of nursing care (87.9%); Cost savings for the health service (84.8%); User satisfaction with the health care provided (78.8%). There were no suggestions for other items.

Regarding weaknesses, the most cited were execution of bureaucratic and administrative activities (69.7%) and insufficient human resources in health services (66.7%). Among the suggestions added by the nurses, the following emerged: conflict with doctors who do not accept the EAP, doctor-centered practice and work overload.

DISCUSSION

The characterization of the sample in this study was similar to the research that mapped EAP actions developed in Brazilian PHC⁽⁸⁾. The proportion of nurses with more than 10 years of experience was lower than the research that carried out the cross-cultural validation of an EAP competency assessment instrument for Brazil, which showed 76.9% of nurses with up to 10 years of training⁽⁹⁾. Regarding the professional training of the participants in this study, specialization also appeared in other studies predominantly among professional nurses^(8,9).

The majority of nurses considered their professional training/performance to develop the EAP partially sufficient and justified the response to the need for appropriate training for the role of APN, confirming results found in another study⁽⁸⁾.In this regard, it is noteworthy that there are discussions in Brazil about the possibility of validating the skills of experienced nurses with a wealth of knowledge, but regardless of this, there is a need for formal validation of this experience,⁽³⁾so that, rigorously, these professionals go through a process of qualified complementary education to train advanced practice nurses^(3,6).In Brazil, postgraduate courses in the professional master's modality have great potential to enable PAE, as they aim to train professionals to perform their occupational practices, which in this case of nursing, could focus on advanced nursing practices⁽¹⁰⁾. From this point of view, authors draw attention to an aspect that demands to be restructured: the fact that postgraduate programs offer predominantly theoretical training^(2),since training of the EPA demands in-depth theoretical-practical knowledge, with practical hours dedicated to clinical learning^(3,11).

Potentialities

The possibility of adopting and implementing clinical nursing protocols was the most cited item among the potential for implementing EAP in PHC mentioned by participants. Such tools are a way to overcome the challenges and obstacles of nurses' clinical practice, providing advanced patient assessment and safe practice ⁽¹²⁾.Furthermore, clinical protocols are considered innovative strategies in the PHC scenario,⁽¹²⁾having a positive impact on qualification care provided to the population. Regarding PAE, in many of the countries where it is already consolidated, it is guided by guidelines based on scientific evidence and inserted into the national health system, which serve as guiding instruments for managing care in a health situation⁽¹⁾, allowing the EPA, after a robust training process, to add better evidence of care to practice.

In the Brazilian reality, Primary Care nursing relies on protocols and guidelines made available by the Ministry of Health, enabling these professionals, as long as they are established as a routine in health services, to prescribe medications and carry out specific procedures⁽¹³⁾.However, authors draw attention to the fact that prescribing medications in Brazil does not require specific training, creating situations in which professionals are poorly prepared to play this role⁽¹⁴⁾.And it is in this logic that the training process in advanced practice gains strength, given that it proposes the development of skills and competencies⁽³⁾directing nurses to reach their full potential and develop quality healthcare, as the nurses in this study believe. Therefore, the expanded roles of APN differ in relation to autonomy in decision-making, carrying out diagnoses and treatments, clinical leadership and case management^(3,15).

Regarding the increase in resoluteness and the qualification of nursing care cited by most nurses as a potential for the implementation of EAP, the result corroborates the conception that this practice is characterized by being a model of resolutive, effective and effective care. autonomous⁽³⁾.The study showed that advanced nursing interventions enabled patients to have better clinical effectiveness, greater adherence to control measures, a reduction in acute situations requiring the use of urgent and emergency services, in addition to a reduction in hospital admissions⁽¹⁶⁾.

Concerning the resoluteness and qualification of nursing care being potential aspects for the implementation of PAE, the reasons for establishing such practices in Brazilian PHC are highlighted, as mentioned by COFEN's CPAE, namely: expanding the population's access to services of health; nurse autonomy to work with different groups in the community; assistance and accountability for health care in places with insufficient doctors; advances in the management of the health system with actions aimed at better results; changing the profile of nursing skills; among others⁽⁷⁾.

Accordingly, a systematic review proved that nurses have better adherence to guideline recommendations and their patients are more likely to have return appointments, which can positively impact health outcomes, in addition to reducing costs in the medium and long term⁽¹⁷⁾, reinforcing what the nurses in this study also understand to be a potential for implementing EAP in PHC. Chile, the only country in Latin America and the Caribbean with the practice implemented to date, has recognized that PAE is a cost-effective health model and has dedicated itself to establishing APN in PHC centers⁽¹⁸⁾.Research carried out in Spain showed that, among the home visits carried out by APN in emergency calls, a small part of these required additional assistance from a medical professional or referral to hospitals ⁽¹⁹⁾.In this way, it is understood that AEP, in addition to providing greater resolution and quality of health care also impacts cost savings for health systems.

Another issue that emerges as potential concerns user satisfaction with the health care provided through care that involves APN, corroborating studies^(17,20)that showed high levels of satisfaction among patients who received care through PN and, some cases, demonstrated even better results than care provided by doctors⁽²¹⁾. In this sense, it is understood that the EPA, after going through a high-level training process, performs a differentiated health care model, guided by comprehensive and humanized, suggesting greater bonding with patients and satisfaction with the care received.

Weaknesses

Regarding the weaknesses in the implementation of PAE in PHC, bureaucratic and administrative activities stand out in the results, corroborating findings in another study that showed that such activities are increasingly increasing among the tasks of nurses who work at this level of care,⁽²²⁾ causing tension with the need to perform their care function and work overload. This reality hinders the expansion of the nurse's clinic,⁽²³⁾ causing much patient care to be the responsibility of nursing assistants and technicians, distancing nurses from direct care to patients.

In the nurses' view, the lack of human resources in PHC services also represents a weakness in the implementation of the EAP. It is noteworthy that the shortage of human resources in PHC health services was evidenced in another study,⁽²³⁾which results in significant gaps in care, such as, for example, health promotion and disease prevention actions. Furthermore, the lack of health professionals is accentuated by the disproportionate distribution of professionals and the shortage of qualified workers,⁽²⁴⁾a fact further aggravated by the Covid-19 pandemic scenario.

Considering the aspects that concern the medical category as a weakness for the performance of the PAE, it is worth highlighting that, regarding its implementation, obstacles with the medical category were also part of the history of countries that currently have consolidated practice⁽¹⁸⁾. In However, recent research showed that the prospects for improvements in public health with the implementation of the EAP surpassed the interests of medical associations, providing an open path for the expansion of the practice of Chilean nurses⁽¹⁸⁾. This reality was associated with the fact that they had a robust plan for implementing EAP in the country was defined, making them aware of the importance of nursing activities ⁽¹⁸⁾.

Specifically, dealing with the prescriptive practice of medicines by nurses, Chile has been developing concrete measures to enhance the proposals suggested by PAHO in the Primary Care scenario, in which planning aims for doctors and nurses to work simultaneously, seeking improvements in chronic conditions and the expansion of access to health services⁽¹⁸⁾. Otherwise, some countries have adopted the methodology of two standards of prescribing nurses: independent and supplementary, being determined according to the training for such ⁽²⁵⁾. Another example to be followed occurs in Finland, where the medical professional has symbolized being a cooperator for the development of advanced nursing functions in PHC⁽²⁶⁾.

Having said this, it is necessary to deconstruct the idea that PAE is a professional competition between nurses and doctors⁽²⁷⁾ and reconstruct the characterization of it as a practice developed by professionals with more autonomy, enabling the doctor to provide health care to patients who really require care from this professional. It is noteworthy that PHC, marked by the collective aspect, required the reorganization of work processes, the expansion of interprofessional boundaries and the sharing of skills between different professionals, enabling some actions, previously exclusive to the medical category, to become also performed by nurses⁽²⁸⁾. Therefore, through PAE it is possible to expand interprofessional practices, enabling actions previously carried out exclusively by doctors to also be offered by nurses, favoring teamwork and the organization of work processes.

In order to overcome weaknesses related to doctors for the implementation of PAE in Brazil, it is essential to include the medical category in part of the process to clarify the context and solidify partnerships. Furthermore, for the PAE to be implemented and well-positioned in health services, it is necessary to advance discussions, clarify and determine the core competencies for the formation of the EPA and adapt them to the realities of each country ⁽²⁹⁾.

Study limitations

Limiting factors include the fact that the collection instrument had not been previously tested, the intentionality of the sample and the territorial scope in which the research was developed, which addresses aspects related to a particular context and cannot be considered generalizable.

Contributions to practice

As contributions, the study provides an overview of the analysis of a reality, demonstrating the potentialities and weaknesses for implementing the PAE, which can be taken as an example for new studies in other realities, providing research support for the new function in the country.

CONCLUSION

The study identified potentialities and weaknesses for the implementation of EAP in PHC based on the understanding of nurses who experience the challenges, complexity and strengths linked to nurses' work in their daily lives, highlighting more strengths than weaknesses. The qualification of the nursing care practice stood out as a potential and, management and planning of work processes and medical-centered practice, as weaknesses. Thus, the implementation of PAE in PHC emerged in this study as a potential action that, through training aligned with the health care model, emerges as a strategy to provide better health results for the population.

REFERENCES

1. Toso BRGO. Práticas avançadas de enfermagem em atenção primária: estratégias para implantação no Brasil. Enferm Foco [on-line]. 2016 [citado 2022 Fev 10];7(3/4):36-40. Disponível em: http://revista.cofen.gov.br/index.php/enfermagem/article/view/913/343

2. Miranda Neto MV, Rewa T, Leonello VM, Oliveira MAC. Advanced practice nursing: a possibility for Primary Health Care?. Rev bras enferm. 2018;71(suppl):716-721. https://doi.org/10.1590/0034-7167-2017-0672

3. International Council of Nurses. Guidelines on advanced practice nursing [on-line]. Genebra: ICN; 2020 [citado 2022 Fev 10]. Disponível em: https://www.icn.ch/system/files/2021-07/ICN_APN%20Report_EN.pdf

4. Oldenburguer D, Cassiani SHB, Bryant-Lukosius D, Valaitis RK, Baumann A, Pulcini J, et al. Implementation strategy for advanced practice nursing in primary health care in Latin America and the Caribbean. Rev panam salud pública [on-line]. 2017 [citado 2022 Fev 10];41:1-8. Disponível em: https://scielosp.org/scielo.php?script=sci_arttext&pid=S1020-49892017000100603&lang=pt#.

5. Pan American Health Organization, World Health Organization. CD52.R13: Human resources for health: increasing access to qualified health workers in primary health care-based health systems [on-line]. Washington: PAHO/WHO; 2013 [citado 2022 Fev 10]. Disponível em: https://iris.paho.org/handle/10665.2/4441.

6. Organização Pan-Americana da Saúde, Organização Mundial da Saúde. Ampliação do papel dos enfermeiros na atenção primária à saúde [on-line]. Washington: OPAS/OMS; 2018 [citado 2022 Fev 10]. Disponível em: https://www.biosanas.com.br/uploads/outros/artigos_cientificos/21/7b49302f4fed08cd6ef3a3967c5ee5f2.pdf

7. Conselho Federal de Enfermagem (BR). Comissão de Práticas avançadas em Enfermagem [on-line]. 2017 [citado 2022 Maio 10]. Disponível em: http://www.cofen.gov.br/wp-content/uploads/2017/04/Apresenta%C3%A7%C3%A3o-_-Leonardo-e-Edson.pdf

8. Almeida EWS, Godoy S, Silva IR, Dias OV, Marchi-Alves LM, Mendes IAC. Mapping of advanced practice nursing actions in the Family Health Strategy. Rev Bras Enferm. 2021;74(Suppl 6):e20210228. https://doi.org/10.1590/0034-7167-2021-0228

9. Minosso KC, Toso BRGO. Transcultural validation of an instrument to evaluate Advanced Nursing Practice competences in Brazil. Rev Bras Enferm. 2021;74(Suppl 6):e20210165. https://doi.org/10.1590/0034-7167-2021-0165

10. Mattos-Pimenta CA, Coca KP, Amorim MHC, Belasco AGS, Gabrielloni MC, Schirmer J. Women’s health care in advanced practice nursing: a professional master’s degree program. Acta Paul Enferm. 2020;33:eAPE20200123. https://doi.org/10.37689/acta-ape/2020ae01235

11. Love R, Santana RF. Advanced nursing practice training: the reality of the United States and the first steps of Brazil. Rev Esc Enferm USP. 2022 Jul 4;56(spe):e20210501. https://doi.org/10.1590/1980-220X-REEUSP-2021-0501en. PMID: 35781325.

12. Kahl C, Meirelles BHS, Cunha KS, Bernardo MS, Erdmann AL. Contributions of the nurse’s clinical practice to primary care. Rev bras enferm. 2019;72(2):354-359. https://doi.org/10.1590/0034-7167-2018-0348

13. Brasil. Lei nº 7.498, de 25 de junho de 1986. Dispõe sobre a regulamentação do exercício da Enfermagem e dá outras providências. Diário Oficial da União. 1986 Jun 26;(seção 1):9.273-9.275.

14. Nascimento WG, Uchôa SAC, Coêlho AA, Clementino FS, Cosme MVB, Rosa RB, et al. Medication and test prescription by nurses: contributions to advanced practice and transformation of care. Rev Latino-Am. Enfermagem. 2018; 26(e3062). https://doi.org/10.1590/1518-8345.2423-3062

15. Andriola IC, Sonenberg A, Lira ALBC. A compreensão da prática avançada de enfermagem como um passo à sua implementação no Brasil. Rev pana salud pública. 2020;44:e115. https://doi.org/10.26633/RPSP.2020.115

16. López MIM, Montoya IM, Lozoya RM, Pérez AE, Caballero VGC, Hontangas AR. Impacto de las intervenciones enfermeras en la atención a la cronicidad en España: revisión sistemática. Rev Esp Salud Pública [on-line]. 2018 [citado 2022 Fev 10];92(e201806032). Disponível em: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1135-57272018000100501&lng=pt&nrm=iso

17. Laurant M. et al. Nurses as substitutes for doctors in primary care. Cochrane Database Syst Rev. 2018;7(7):CD001271. https://doi.org/10.1002/14651858.CD001271.pub3

18. Aguirre-Boza F, Mackay MCC, Pulcini J, Bryant-Lukosius D. Implementation strategy for advanced practice nursing in primary health care in Chile. Acta paul enferm. 2019;32(2):120-28. https://doi.org/10.1590/1982-0194201900018

19. Alonso SRL, Rodríguez CL, Caravante SM, García AIM. Asistencia urgente domiciliaria a personas con problemas crónicos de salud por la enfermera de cuidados avanzados. Gerokomos [on-line]. 2019 [citado 2022 Fev 10];30(3):108-12. Disponível em: https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1134-928X2019000300108&lang=pt

20. Kurtzman ET, Barnow BSA. Comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Med care. 2017;45(6):615-622. https://doi.org/10.1097/MLR.0000000000000689

21. Swan M, Ferguson S, Chang A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health Care. 2015;27(5):396-404. https://doi.org/10.1093/intqhc/mzv054

22. Conselho Federal de Enfermagem, Fundação Osw6aldo Cruz. Relatório final da Pesquisa Perfil da Enfermagem no Brasil [on-line]. Rio de Janeiro: COFEN/FIOCRUZ; 2017 [citado 2022 Fev 10]. Disponível em: http://www.cofen.gov.br/perfilenfermagem/pdfs/relatoriofinal.pdf

23. Biff D, Pires DEP, Forte ECN, Trindade LL, Machado RR, Amadigi FR, et al. Nurses’ workload: lights and shadows in the family health strategy. Ciênc Saúde Colet. 2020; 25(1):147-158. https://doi.org/10.1590/1413-81232020251.28622019

24. World Health Organization. Global strategy on human resources for health: workforce 2030 [on-line]. Geneva: WHO; 2016 [citado 2022 Fev 10]. Disponível em: https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf?sequence=1

25. Maier CB. Nurse prescribing of medicines in 13 European countries. Hum Resour Health. 2019;17(1):95. http://dx.doi.org/10.1186/s12960-019-0429-6

26. Delamaire M-L, Lafortune G. Nurses in advanced roles: a description and evaluation of experiences in 12 developed countries [on-line]. França: Organisation for Economic Co-operation and Development; 2010 [citado 2022 Fev 10]. Disponível em: http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=delsa/hea/wd/hwp(2010)5&doclanguage=en

27. Silva M, Lemos A, Baroni DA, Mauro LA, Tomacheski MO, Marciano VC. Enfermagem de Práticas Avançadas: caminhos para implantação. Ver Científica Multidisciplinar [on-line]. 2019 [citado 2022 Fev 10]:6(12):65-81. Disponível em: https://www.nucleodoconhecimento.com.br/saude/caminhos-para-implantacao

28. Pereira JG, Oliveira MAC. Nurses’ autonomy in primary care: from collaborative practices to advanced practice. Acta paul enferm. 2018; 31(6):627-35. http://dx.doi.org/10.1590/1982-0194201800086.

29. Quiroz PAE, Toso BRGO. Advanced practice nursing in Latin America and the Caribbean: seeking its implementation. Rev bras enferm. 2021;74(Suppl 6):e74suppl601. https://doi.org/10.1590/0034-7167.202174suppl601

All authors contributed to the following items: 1. conception and/or planning of the study; 2. obtaining, analyzing and/or interpreting data; 3. writing and/or critical review and final approval of the published version.

There is no development institution. There are no thanks.

Scientific Editor: Francisco Mayron Morais Soares. Orcid: https://orcid.org/0000-0001-7316-2519

Rev Enferm Atual In Derme v. 97;(3) 2023 e023154

Atribuição CC BY

Variable	n (%)
Experience at APS (years)
< 1	2(6,0)
1 – 5	7(21,2)
5 – 10	7(21,2)
10 – 20	15(45,6)
> 20	2(6,0)
Hiring Form
Public contest (state employee)	15(45,6)
Outsourced contract through selection process	13(39.3)
Residents in Family Health	4(12,1)
Temporary contract	1(3,0)
Academic training (maximum degree)
Graduation	3(9,1)
Family Health Residency	3(9,1)
Especialization	25(75,8)
Academic master's degree	1(3,0)
Professional master's degree	1(3,0)
Acting service
Family Health Strategy	14(42,4)
Specialized service	6(18,2)
Health center or Basic Health Unit	5(15,2)
Residents in Family Health	4(12,1)
Management and planning	3(9,1)
Epidemiological monitoring	1(3,0)

Potentials and weaknesses for the implementation of Advanced Nursing Practice	n (%)
Potencialities*
Practice guided and supported by protocols with scientific evidence	32(97,0)
Harnessing the full potential of nurses	30(90,9)
Increased resolvability	30(90,9)
Qualification of nursing care	29(87,9)
Cost savings for the healthcare service	28(84,8)
User satisfaction with the health care provided	26(78,8)
Humanization of nursing care	25(75,7)
Strengthening bonds with patients	24(72,7)
Organization of the nurse's work process	24(72,7)
Ease of access to health services	22(66,7)
Possibility of promoting teamwork	17(51,5)
Possibility of achieving a professional status of greater respect	15(45,6)
Performance of health care previously performed by a doctor	14(42,4)
Weaknesses*
Bureaucratic and administrative activities	23(69,7)
Insufficiency of human resources in health services	22(66,7)
Performance of health care previously performed by a doctor	7(21,2)
Organization of the nurse's work process	7(21,2)
Conflict with doctors who do not accept EAP and physician-centered practice	2(6,0)
Work overload	2(6,0)