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1 Disclosure presenter

2 2 The Advanced Practice Nurse role: What is one Brazilian university s understanding and readiness? ANDRÉA SONENBERG, PHD, WHNP, CNM-BC, FNYAM, FNAP BERTHA CRUZ ENDERS, RN, PHD

3 An International Collaboration 3 Pace University (New York, USA) and Universidad Federal do Rio Grande do Norte (Natal, Brazil) Andréa Sonenberg, PhD, WHNP, CNM-BC and Bertha Cruz- Enders, PhD, PNP 2009-Present

4 Introduction Globally, disparities persist among health access and health outcomes. Nurses make up 80% of the world s health care workforce, while they are practicing under varying titles and at varying levels in different countries. The literature reports that in some countries, nurses are practicing at advanced levels, regardless of their formal education or license. The WHO (2016) recommends that advanced level nurses be at the forefront of health delivery system, design, delivery, and oversight of care. Some nursing stakeholders, including several in Latin America, are indicating interest and readiness to introduce the advanced practice nurse (APN) role. 4

5 Global Health Disparities 5 Country Male Female Belgium Denmark Brazil Colombia Non-communicable diseases, Age-standardized NCD mortality rate (per population-2016). (WHO, 2018a)

6 Global Health Workforce Capacity (2013) Country Physician Workforce Nurse Workforce 6 Belgium Denmark Brazil Colombia 2.96 doctors/1,000 population 3.65 doctors/1,000 population 1.85 doctors/1,000 population 1.77 doctors/1,000 population nurses/1,000 population nurses/1,000 population 7.44 nurses/1,000 population 1.03 nurses/1,000 population (WHO, 2018b)

7 Brazil: Family Health Strategy (FHS) - a federal program designed to provide integrated primary health care to all individual in the Unified Health System; using a multi-disciplinary team, in which nurses play a leading role. (Macinko & Harris, 2015) 7 414,712 nurses in Brasil (COFEN, 2018)

8 UFRN: Considerations for an APN experience 8 Current discussion by Organized Nursing in Brazil for development of a national APN model; APN innovation and change for all stakeholders in the healthcare system context in Brazil; Nurses awareness of forthcoming discussions on APN, its implementation, education, regulation, and other issues, as essential; Introductory course on APN by a certified practitioner, to enhance nurses awareness of its concepts, role, and implications; UFRN visiting professorship award to PACE Universary certified-practitioner and faculty member for the development of APN course in collaboration with Brazilian nursing faculty member

9 UFRN: The APN Course Locality: Post-Graduate Nursing Program/ UFRN/Natal Brazil; September 11-15, 2017 Title: Introductory Course on Advanced Nursing Practice, 9 Professor: Andréa Sonenberg, PhD, WHNP, CNM-BC; Associate Professor - Pace University, College of Health Professions The Course: Elective 3 credit hrs for Masters and Doctoral Students; Audit privileges for non-student nurses and faculty; Intensive format (40 hrs in-cass, 05 day dispersion) Content: 5 modules Methods: Lecture and active methodologies. Evaluation: formative and by group paper assignment.

10 UFRN: The Course Modules History & Background related to advanced practice nursing (APN) 2. Research evidence related to APN 3. APN Education and professional roles 4. APN Professionalization 5. APN Role in Global Access to Care & Health: Scaling up

11 11 The Study- Survey of Advanced Nursing Practice: Understandings and Perspectives

12 Study Objectives: 12 Explore the nurses perceptions of Advanced Practice Nursing (APN) concepts and role implementation prior to taking the introductory course. Compare the nurses preconceived perceptions of APN concepts and role implementation to their post-course perceptions of the concepts. Analyse the nurses views of APN in relation to its Development in the Brazilian healthcare context Role development for their practice.

13 Assumptions 13 APN is a global phenomenon whereby each country defines the role, and establishes its scope of practice, and regulations. Healthcare delivery and the professional health workforce in Brazil are complex systems, which might benefit from a discussion of the role of APN. Introduction of APN in Brazil would constitute an innovative change in nursing practice and education, as well as the workforce infrastructure of the healthcare system. Informing nurses, the primary stakeholders, about APN and its function in improving access to quality primary healthcare enhances awareness and readiness for the change process.

14 Theoretical Framework: 14 PAR* (Introduction of APN through PEPPA) Diffusion of Innovation Theory (Dissemination of APN innovative role) Organizational Change Theory (readiness for change) *Participatory Action Research (Bryant-Lukosius & DiCenso, 2004; Rogers, 2003; Weiner, 2009)

15 Design and participants 15 Exploratory descriptive study Component of major research project with IRB/UFRN approval All participants signed an Informed Consent Form Purposive Sample: All 44 nurses attending the UFRN Course Intensive. 38 post-graduate nursing students 03 hospital nurses 03 faculty members

16 Data collection: 16 Pre- and post-course surveys 1 st and last day of the course Self-administered questionnaire - 3 open-ended questions on their: Understanding of APN Perceptions of obstacles and barriers to the nurse practitioner (NP) role in the local context Perception of self in the NP role in the work setting - If positive, the enabling conditions present for the role - If negative, the obstacles needing reform for implementation of the role

17 Data analysis procedure: Content analysis Laurence Bardin (2011)approach to qualitative analysis in the thematic mode. Units of meaning - identified and extracted from the surveys data, coded, classified, grouped by similarity, and quantified to form the thematic categories pertaining to each question. Thematic categories - named and organized according to the predominant elements, reclassified and regrouped in three analytic thematic results Perceptions of APN concept Perceptions of barriers and obstacles Facilitators to the APN role as perceived by nurses POSITIVE and NEGATIVE to undertaking the role Interpretation of the analytic thematic results - theoretical framework that guided the study and the study objectives. 17

18 Results Table 1. Perceptions of Advanced Practice Nursing (APN) 18 Pre-course survey Units Post-course survey Units Qualified autonomous actions 32 Mental process for care decision-making 37 Specialized function, leadership atributes 30 Specific complex care competencies 35 Requires clinical competencies/knowledge 29 Autonomous scientific-based specialty care 27 Critical decision-making reasoning 18 Requires post-graduate Ed/knowledge 24 Improves nursing care and the discipline 15 Impacts healthcare resolution and costs 24 A Nursing practice branch of excellence 12 Integral sistematized patient-centered care 12 Improves healthcare 8 Requires change and adaptation to context 2

19 Results Analytic theme 2 19 Table 2. Barriers to the APN role in the work setting. Pre-Course Survey Units Post-course survey Units Unreceptive work environment 48 Nursing s political disarticulation 17 Lack of nurse preparedness 26 Medical hegemony 16 Professional nursing problems 17 Lack of nurse preparedness 15 Social related issues 9 Lack of institutional support 11

20 Results: Table 3 Envisioning self in the APN role in the work context. 20 Responses Pre-Course Survey Post-Course Survey Response Rate 100% (N=44) 73% (N=32) Positive Response 68% (N=30) 81% Facilitating conditions 6 4 Other Conditions Needed 5 3 Negative Response 32% (N=14) 11% (N=5) Other Conditions Needed 3 4

21 Results 21 Table 4. Facilitating conditions to APN as perceived by nurses POSITIVE to undertaking the role in the local work setting Pre-course Survey 68% of respondentes - Facilitating Conditions Nurses interest and willingness to learn Established primary health care settings Obstetrical and some primary care nurses already acting autonomously Existing post-graduate support for APN role Suficient nursing workforce available for such practice Recognized benefits of APN role Post-course Survey 81% of respondents - Facilitating Conditions Nursing knowledge base and professional skills supportive of the role Existing nursing practices similar to APN actions Existing health system as appropriate setting for the role Post-graduate educational programs in nursing available

22 Results Table 5. Conditions still needed for APN as perceived by nurses POSITIVE to undertaking the role in local work setting. 22 Pre-Course Survey -30 (68%) of respondents- Conditions still needed for role APN role content in undergraduate and post-graduate education programs Institutional, management and peer support, incentives and resources Organized nursing political discussion on role benefits to APN and safe care Further research on APN impact on health care Nurses experience in the area Post-Course Survey 14 (44%) of respondents Conditions still needed for the role APN training centers to strengthen the nurses knowledge base and preparation for the role Articulation of nursing accrediting bodies and associations in establishing legislative authority for the role

23 Results Table 6. Conditions needed for APN as perceived by nurses NEGATIVE to envisioning selves in the role. 23 Pre-course Survey 23% of respondents- Conditions needed Increased knowledge and skills at undergraduate, specialization education, and qualified faculty Institutional and government support of APN care services, ample nursing workforce and technologies Pro-active professional nursing organizations New paradigm of nursing care Post-course survey - 13% of respondents - Conditions needed Adjustment of undergraduate curricula and educational preparation at postgraduate level with certified APN faculty Political support from policy makers, nursing accrediting bodies and nursing associations Resolution of nursing internal practice problems and unification of nursing accrediting bodies and associations

24 Results Table 7. Comments offered by nurses 24 Themes identified in comments Recognition of the value of APN to quality healthcare, nursing visibility, and to the Brazilian Unified Health System principles Prediction of great delay in APN development in Brazil because of deficiencies in nursing practice and obstacles Units 7 5 Willingness to participate in APN development 4 Course satisfaction and desire for additional educational experiences on APN with visiting professor that ministered course 3 Recommendation for nursing unity and pro-activity in embracing APN 2

25 Addressing the findings of this study 25 Nurses perceptions of APN: Pre-/Post-Course Barriers to introducing the APN Role in the Brazilian context Facilitating conditions Perceived by nurses Favorable to undertaking the APN role Perceived by nurses Negative to undertaking the APN role

26 Study Limitations 26 One-case study design Limited number of participants Data collection limited to self-reported questionnaire.

27 Implications 27 In preparation for national discussions in the area of introducing the APN role and practice in Brazil, small nursing group discussions positively influence the dissemination of the concept of APN and readiness for change in the Brazilian context, and are integral to steps 1-5 of the PEPPA process. To further support these efforts, it is recommended to continue international, inter-university collaborations. Further research on the APN role in Brazil Feasibility Implementation

28 Conclusions: Consistent with a participatory process and the PEPPA framework for the introduction and evaluation of advanced practice nursing roles, this course was offered at UFRN and its neighboring nurses to fulfill steps 1-5 of the PEPPA model. According to Diffusion of Innovation theory, an idea or product gains momentum and diffuses (or spreads) through a specific population or social system over time originating in the communication of the conceptual foundation of the idea or project. Engaging Brazilian nurses themselves to participate in a smaller local discussion of the APN concepts, enabled them to reflect on some of its related issues. These included: the concept of the APN role itself, its potential impact within the Brazilian context, and the obstacles and facilitators of its implementation within their own country s context. Most of the nurses in the group have a positive attitude towards incorporating the role into the Brazilian health care system, but still foresee some important changes to be made to facilitate the implementation of the APN role in Brazil. 28

29 This case study of a group of Brazilian nurses identified their perspectives of existing barriers and the necessary conditions to achieve APN implementation within their country s context. The experiences of the international community where the APN role has been implemented should inform any implementation process, within the PEPPA framework. 29 Based on Weiner (2008) conceptual discussion of readiness for change as having two dimensions--motivation and capabilities--it is concluded that the nurses willingness and positive attitudes towards the APN role addresses the motivational aspects of the concept readiness, while seeking to obtain the resources, opportunity and the expertise to implement the change begins to address gaining the capabilities.

30 References Bryant-Lukosius D, DiCenso A. A framework for the introduction and evaluation of advanced practice roles. J Adv Nurs 2004; 48(5): Conselho Federal de Enfermagem (2018). Retrieved from Halcomb EJ, Davidson PM, Griffiths R, Daly J. Cardiovascular disease management: time to advance the practice nurse role? Australian Health Review 2008;32(1): Kleinpell R et al. (2014). Addressing Issues Impacting Advanced Nursing Practice Worldwide OJIN: The Online Journal of Issues in Nursing. 2014: 19(2) Manuscript 5. Retrieved from /Advanced-Nursing-Practice-Worldwide.html Macinko, J., & Harris, M. J. (2015). Brazil's family health strategy--delivering community-based primary care in a universal health system. The New England Journal Of Medicine, 372(23), doi: /nejmp McKenna L An investigation of barriers and enablers to advanced nursing roles in Australia. 2015: Collegian 22: Available from ScienceDirect.com. Accessed 07 July Oldenburger D et al. Implementation strategy for advanced practice nursing in primary health care in Latin America and the Caribbean. Rev Panam Salud Publica. 2017;41:e40. Rogers EM. Diffusion of innovations. 5th ed. New York:Free Press; Weiner BJ, Amick H, Lee SYD. Conceptualization and measurement of organizational readiness for change. Med Care Res Rev 2008; 6(54): World Health Organization. (2016). Health workforce requirements for universal health coverage and the sustainable development goals. Retrieved from World Health Organization. (2018a). Global Health Observatory data repository: Non-Communicable Diseases Mortality. Retrieved from World Health Organization. (2018b). Global Health Observatory data repository: Health Workforce Density per 1,000. Retrieved from Zug KE et al. Advanced practice nursing in Latin America and the Caribbean: regulation, education, and practice. Rev Latino Amer Enfermagem :e

31 31 Thank you for your attention!