South American legal perspective on professional nursing.

South American legal perspective on professional nursing Fagner Alfredo Ardisson Cirino Campos and Oleg Nekrassovski

Key words: The Nurse Practice Act ■ Nursing professional ■ Registered nurse ■ South America

H

uman beings are vulnerable to disease processes. Hence, nursing can be defined, according to J Watson (McEwen and Wills, 2009), as the science of human caring, which may be mediated by personal subjectivity, as well as professional, scientific, aesthetic, ethical and political variables (Lima, 2005). According to some laws in South America, nursing is a science of providing biopsychosocial and spiritual care at the patient, family and community levels; aiming at completeness, individuality of care, good communication, and satisfaction of basic human needs, as well as high-quality and continuity of care. The main field of nursing is grounded in health promotion and disease prevention, intervention, rehabilitation, recovery, and maintenance of comfort and quality of life (Decreto n. 2.497 of 1993 (Argentina), s.1; Ley n. 266 of 1996 (Colombia), s.1; Decreto Supremo n. 004 of 2002 (Perú), s.1; Ley de ejercicio profesional de la enfermería of 2005 (Venezuela), s.1; Decreto n. 11.381 of 2007 (Paraguay), s.3; Ley n. 18.815 of 2011 (Uruguay), s.1). Nursing in recent decades has become more technical and specialised, but also less intuitive; contributing to significant changes in the role and functions classically attributed to nurses (Oguisso and Schmidt, 2010). Fagner Alfredo Ardisson Cirino Campos is Postgraduate Student, Federal University of Rondônia, Ji-Paraná, RO., Oleg Nekrassovski is Postgraduate Student, Royal Military College of Canada Accepted for publication: July 2013

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Methodology South America is composed of Argentina, Bolivia, Brazil, Colombia, Chile, Ecuador, Paraguay, Peru, Uruguay and Venezuela; all being countries with republican and democratic political systems (Almeida and Rigolin, 2005). The research

© 2013 MA Healthcare Ltd

Abstract

This study involved a literature review aimed at describing the professional duties, stipulated in federal legislation, of nursing professionals in South America. According to the federal legislation that regulates the professional nursing practice, nurses are supposed to apply their skills and knowledge in an autonomous and secure way. Since it is through this legislation that professional competence of nurses is determined, the laws of each South American nation were consulted, to see how professional nursing functions differ according to each. In general, according to the South American federal nursing legislations, professional nursing practice must be grounded in quality patient care and good nursing administration.

Different types of nurses began to stand out in the multidisciplinary team as professionals who help in the rehabilitation, and may prescribe medications (a trivial action in several countries, including Brazil, as determined by protocols) (Oguisso and Freitas, 2007), perform episiotomies (surgically planned incisions on the perineum and the posterior vaginal wall during second stage of labour) and episiorrhaphies (surgical repair to the vulva by suturing) (as performed by Brazilian certified nurse-midwives) (Decreto n. 94.406 of 1987 (Brazil), s.1), administer anesthesia without physician supervision (as is the case for US nurse anesthetists where state laws permit) (Centers for Medicare and Medicaid Services, 2001); and recently Brazilian nurses have been shown to be highly qualified to monitor and provide targeted outpatient care to vegetarians (Campos et al, 2011). The professional practice of nursing is regulated by constitutional law, statutory law, (for example Nurse Practice Acts), administrative law, common law, civil law, criminal law and institutional regulations in place for nurses, the ignorance of which does not absolve the professional from being held responsible for committed errors. Thus it is necessary that the nursing professionals (RNs) know at least the laws that relate to their practice; since professional rights and duties are primarily specified by legislation. This knowledge may increase the autonomy of the nurse, who is instigated to (re)consider the weaknesses of the professional practice law, in order to modify it, improve it, and adapt it to the sociocultural context in which the nursing professionals operate (Oguisso and Schmidt, 1999; Timby, 2007; Oguisso and Schmidt, 2010). The aim of the presented work was to determine the skills, professional responsibilities, and rights guaranteed to nurses by federal legislation; as well as to outline and discuss the boundaries of the professional practice of nursing as set by the federal nursing laws. These laws are similar to the Nursing Practice Acts in the US, but in South American countries such laws are at the federal rather than the state level. Therefore, the study describes the varieties of nursing professionals in South America, their supervising organisations, as well as professional competencies of South American RNs, in light of existing federal laws regulating the professional practice of nursing.

British Journal of Nursing, 2013, Vol 22, No 14

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Level of education

Bachelor’s degree (RN)

Country

ENF

Argentina

X

Bolivia

X

X

Brazil

X

X

Chile

X

Colombia Ecuador

PE

PUE

Below bachelor’s degree TE

AE

P

X X X

X

X

X X

X

X X

X

Uruguay Venezuela

EO

X

Paraguay Peru

LE X

X

X

X

X

X

X

X

X

Legend: ENF: enfermeiro/enfermero (RN); PE: profesional de enfermería (RN); PUE: profesión universitaria de enfermería (RN); LE: licenciado en enfermería (RN); EO: Enfermeiro Obstetra/ Enfermero Obstetriz (obstetrical nurse/RN); TE: técnico en enfermería/ técnico de enfermagem/ técnico médio en enfermería/ Técnico Superior en Enfermería (nursing technician), AE: auxiliar de enfermería/auxiliar de enfermagem (nursing assistant); P: parteira (midwife) Table 2. Organisations responsible for the supervision of nursing professionals in South America Country

Professional supervision MS

Argentina

X

Bolivia

X

Brazil Chile

COFEN/ COREN

CE

X X

X X

Ecuador

X

Paraguay

X

Peru Venezuela

FE

X

Colombia

Uruguay

ANEC

X X

X X

Legend: MS: Ministerio de Salud (Ministry of Health); COFEN/COREn: Conselho Federal de Enfermagem/Conselho Regional de Enfermagem (Federal Board of Nursing / Nursing Regional Council); CE: Colegio de Enfermeras (College of Nursing); ANEC: Associación Nacional de Enfermero (National Association of Nurses); FE: Federacion de enfermeras y enfermeros (Federation of Nurses)

merely seeks federal legislation that regulates the nursing profession in these countries. A literature review was conducted from September– November 2012. The search was conducted in the integrative research database VHL-Leyes (Virtual Health LibraryLaws), vLex (basic legal information), GLIN (Global Legal Information Network), and the legal databases of regulatory agencies, congresses, senates, and assemblies of various South American countries. The search was random and using, where necessary, the language of the bank. The search used the following Spanish keywords: ■■ ‘Enfermería’

838

■■ ‘La

ejercicio enfermería’ legislación’ ■■ ‘Enfermera’ ■■ ‘Ley de la enfermería’. The following Portuguese keywords were also used: ■■ ‘Exercício legal de enfermagem’ ■■ ‘Lei do exercício profissional de enfermagem’ ■■ ‘Legislação de enfermagem’ ■■ ‘Enfermeira’. To meet the proposed goal, the authors included only those legislative documents, about the nursing profession, that applied to whole federations of each South American nation and had laws specific to nursing. Local, state, or other such laws specific to nursing were excluded, because they aren’t related to the nursing laws at the federal level. Also excluded were other federal laws that apply to all regulated professions and citizens in general. The keyword search yielded 42 legal documents out of which only 14 were relevant federal legislation. These 14 documents were analysed and categorised for the country of origin, law/decree number, nursing category, functions or powers of the professional nursing boards, the definitions of nursing science and nursing research, and the local language in which the legislation was drafted. ■■ ‘Enfermería

Results Characterisation It was noticed that 85.7% (12) of legislative documents were written in Spanish and the rest in Portuguese. And that 35.7% (5) of the legislative documents did not provide a definition of nursing science. These five legislative documents represent three South American countries. Table 1 shows that in the seven countries RN is called ‘enfermeiro’ in Portuguese and ‘enfermero’ in Spanish, the rest of South American countries label such professionals, in legislation, with another title. The laws consulted also show that there are nursing professionals without a Bachelor’s degree in South America. Table 2 demonstrates that in six countries the nursing professionals are supervised by the Ministry of Health, in four countries by the College of Nursing, and the other countries have other agencies/entities doing this kind of supervising.

Professional skills of RNs As the table in Appendix I indicates, South American RNs possess common skills related to the administration of nursing services and nursing care. Moreover, health promotion and disease prevention, as well as research and education, also have demonstrated relevance to the practice of nursing in South America.

Discussion The law is the greatest force in Western society. It is a standard or rule, written by legal authorities, following which is mandatory for all citizens. However, laws are only valid for a limited time in a given society. Therefore, it is extremely important that every country has a law that regulates professional nursing practice; the law is supreme and has greater legal force than a resolution of the board that oversees


Table 1. Distribution of nursing professionals in South America by professional title



literature review the profession. Also, such a law guarantees the continuity of the nursing profession and a safe society (Oguisso and Schmidt, 1999; Travaglia, 2002; Merçon and Araujo, 2007). However, if nurses are to successfully exercise their professional skills and knowledge, more than just a law, which regulates the nursing profession, is required. In fact, it is also necessary that nurses have a professional record on the supervisory board of nursing of their country. The powers of these bodies vary depending on the laws of professional practice and other laws of the country, especially the laws regulating such organisations. This surveillance is based on professional nursing law and ethics (Ministerio de la salud Argentina, 2012; Ministerio de la Salud y Deportes de Bolivia, 2012). Thus, the law governing professional nursing grants rights, defines the profession and its categories, functions, duties and powers, provides legal support, influences the development of curricular guidelines for undergraduate nursing, and determines the expected profile of nurses and their required qualifications (Timby, 2007; Oguisso and Schmidt, 2010). In South America, nursing is split into several categories, RN and others, as shown in Table 1. South American federal law allows RNs to practice nursing through leadership, nursing consultation, prescription nursing, teaching, clinical care and the nursing care of patients and the supervision of the nursing staff (Organización Panamericana de la Salud, 2011). According to the laws surveyed in this study, South American RNs have legal autonomy to carry out prevailing management practices, nursing administration, and nursing care of greater complexity (Organización Panamericana de la Salud, 2011). Despite these uniformities in federal nursing laws across South American nations, considerable differences also exist. In Argentina, for example, RNs can prescribe medications and order laboratory tests (Resolución n. 118 of 2009 (Argentina), s.1). While in Brazil, RNs have the right to request additional tests and routines, provided that there is a previously established governmental or institutional protocol for that (Resolução n. 195 of 1997 (Brazil), s.1; Portaria n. 648 of 2006 (Brazil), s.1). However, the laws of the professional practice of nursing in these countries do not consider the competence of RN in these practices. While in Colombia, the RN has prescribed medicine without legal support, based only on a governmental health programme (Zamora et al, 2010).


Further research and policy recommendations The rights, powers, duties, and responsibilities of South American RNs, as indicated by their federal nursing laws, are broad and diverse. This triggers a question as to whether South American RNs value administrative duties more than nursing care. This question is impossible to answer by studying the legislation. It requires observational research of professional nurses. However, it is important to note that a nurse cannot engage in nursing administration without knowing the details of the process through which nurses care for patients, families, and communities (Hausmann and Peduzzi, 2009).


Public health policies aimed at increasing public access to health care, can trigger changes in traditional nursing responsibilities (research, care, comfort and counseling). Such policies may be reinforced by future legislation regulating the profession, as occurs in developed countries, and not only in government resolutions or ordinances (Timby, 2007). Nurses often lack professional visibility by virtue of not being identified by the patient/client as professionals that help in the treatment and rehabilitation of patients (Stacciarini et al, 1999). In the past, in South America, there was a nurse who only cared for the sick, and was commonly called ‘nurse’ (Malagutti and Miranda, 2011). When the legislation does not define professional nursing and its scientific domain, a gap, which leads to the mischaracterisation of the professional nurse, may be created, contributing to the creation of a society that can neither describe nor understand the scope of professional nursing work. Hence, it is important that the representatives of professional nursing organisations propose, to the federal legislature, a preliminary bill of professional practice, about describing the scope of the nursing profession in federal legislation (Decreto n. 94.406 of 1987 (Brazil), s.1; Ley n. 19.536 of 1997 (Chile), s.1; Decreto Reglamentorio n. 492 of 1999 (Ecuador), s.1; Oguisso and Schmidt, 2010).

Conclusion Nursing is a profession that has gained rights and duties through legislation, legitimising the exercise of nurses’ professional skills. The times today are different from the early days of Florence Nightingale when nursing was not a real science or profession. The nurse of the 21st century is a nurse who holds a degree in nursing, and lives in a world in constant change (whether in science, health information systems, research, economics, or social policy), where there are not enough nurses to achieve their professional rights through legislation, and the law. The nurses of today must know their professional duties and responsibilities and perform them with autonomy and knowledge, always fighting for new professional rights in order to provide quality nursing care to patients, families and communities (Oguisso, 2000). Nursing is a science-based care, which is still undergoing philosophical and technical development. The research, appropriation of scientific knowledge by nurses, and political involvement and mobilisation of nurses’ representatives, will determine the future of nursing, especially its social representation. It is not enough that the roles and responsibilities of nurses are guaranteed by law. Nurses must exercise them daily, in a professional manner that builds their autonomy, visibility and professional recognition. Hence, the need for nurses to know, study, defend, and claim amendments or additions to the laws governing their profession. The knowledge will free BJN the nurses, in every sense of the word. Conflict of interest: Fagner A. A. C. Campos is a practicing registered nurse (RN) in Brazil. He is a memeber of the Brazilian Nursing Association (Aben) and Brazil’s Federal Council of Nursing (COFEN). Almeida MAA, Rigolin TB (2005) Geografia Humana e. Economica Ática, São Paulo, Brasil Campos FAAC, Cheavegatti D, Martins FA, Seixas LA (2011) Enfermeiros no

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Appendix 1. Distribution of professional skills of RNs in South America

Country

Nurse practice act

Clinical practice 1- Nursing consultation 2-Nursing diagnosis 3-Nursing prescription 4-Nursing intervention

Care or critical care 1- Nursing care (medication administration, comfort, venipuncture, etc.)

Teaching 1- Teaching in university and in nursing school

Scientific research 1-Nursing and health.

Consulting 1- Suggest improvements in nursing care, nursing opinion and audit

Health promotion and (or) disease prevention (or) health education 1-Patient education; family and community behavior change

Delegation 1- Delegate nursing activities to other members of the nursing team

Argentina

■■ Ley

(law) n. 24004/1991 ■■ Decreto-ley (decree law) n. 2497/93

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Does not say

Bolívia

■■ Decreto

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Does not say

Brazil

■■ Lei

(law) n. 7.498/1986. ■■ Decreto-lei (decree law) n. 94.406/1987

Yes

Yes, Yes including prescription drugs

Yes

Yes

Yes

Yes

Does not say

Ecuador

■■ Ley

de ejercicio profissional (professional practice act) n.57/ 1998 ■■ Reglamento de aplicación de la ley de ejercicio profesional (regulation of nursing practice act) n.492/ 1999

Yes

Does not say

Yes

Yes

Yes

Does not say

Yes

Does not say

Colombia

■■ Ley

Yes

Does not say

Yes

Yes

Yes

Yes

Yes

Does not say

Chile

■■ Ley

Yes

Does not say

Yes,

Does not say

Does not say

Does not say

Yes

Does not say

Paraguay

■■ Ley

Yes (law) n. 3.206/2007 ■■ Decreto (decree) n. 11.381/2007

Yes

Yes

Yes

Yes

Yes

Yes

Does not say

Peru

■■ Ley

(law) n. 27669/2002 ■■ Decreto-supremo (decree supreme) n. 004/2002-As

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Uruguay

■■ Ley

Yes

Yes

Yes

Does not say

Yes

Yes

Yes

Does not say

Venezuela

■■ Ley

Yes

Does not say

Yes

Yes

Does not say

Does not say

Does not say

Does not say

840

supremo (supreme decree) n. 15463/1978

(law) n. 266/1996 (law) n. 19536/1997

(law) n. 18.815/2011 de ejercicio profesional (nurse practice act), 2005


Activities of South American RNs permitted by federal legislation Administration/ management 1-Planning, direction, organization of nursing services 2- Nursing leadership



literature review cuidado da saúde de vegetarianos. 63rd Congress of Brazilian Nurses, 3–6 October 2011, Maçao, Brazil. http://tinyurl.com/nj8skgu (accessed 16 July 2013) Centers for Medicare & Medicaid Services (2001) Physician Supervision of Certified Registered Nurse Anesthetists. http://tinyurl.com/ka949o4 (accessed 9 July 2013) Hausmann M, Peduzzi M (2009) Articulação entre as dimensões gerencial e assistencial do processo de trabalho do enfermeiro. Texto Contexto Enferm 18(2): 258-265 Lima MJ (2005) O que é enfermagem? Cogitare Enferm 10(1): 71-74 Malagutti W, Miranda SMRC (2011) Os caminhos da enfermagem: de Florence à globalização. Enfermagem em Foco 2(supl): 85-88 McEwen M, Wills E (2009) Bases Teóricas Para Enfermagem. Artmed, Porto Alegre, Brazil Merçon G, Araujo G (2007) Um decreto com força de lei. http://tinyurl. com/o956wjh (accessed 16 July 2013) Ministerio de Salud (Argentina) (2012) Matriculaciones. http://www.msal. gov.ar/index.php/home/matriculaciones (accessed 9 July 2013) Ministerio de Salud y Deportes (Bolivia) (2012) Matricula Profesional. http://tinyurl.com/ojuat3t (accessed 9 July 2013) Oguisso,T (2000) A enfermagem no mundo atual e projeções para o futuro. Acta Paul Enf 13(especial): 44-52 Oguisso T, Freitas GFF (2007) Enfermeiros prescrevendo medicamentos: possibilidades e perspectivas. Rev Bra Enferm 60(2): 141-4 Oguisso T, Schmidt MJ (1999) Sobre a elaboração das normas jurídicas. Rev Esc Enf USP 33(2): 175-85 Oguisso T, Schmidt MJ (2010) O Exercício da Enfermagem: Uma Abordagem Etico-legal. Guanabara Koogan, Rio de Janeiro, Brazil Organización Panamericana de la Salud (2011) Regulación de la enfermería en América Latina. http://tinyurl.com/q3rruuy (accessed 9 July 2013) Stacciarini JM, Andraus LMS, Esperidião E, Nakatani AK (1999) Quem é o enfermeiro? Rev Eletr Enf 1(1): 1-4 Timby BK (2007) Conceitos e Habilidades Fundamentais no Atendimento de Enfermagem. Artmed, Porto Alegre, Brazil Travaglia LC (2002) Gêneros de texto definidos por atos de fala. In: Zandwais, A, eds. Relações entre Pragmática e Enunciação. Sagra Luzzato, Porto Alegre, Brazil: 129-153 Zamora LDC, Londoño CB, Gómez MP (2010) Características de la prescripción por Enfermería en la ciudad de Cali, Colombia. Invest Educ Enferm 28(2): 163-70

n According

to some laws that best define the science of nursing in South America, nursing is a science of providing biopsychosocial and spiritual care at the patient, family and community levels

n This

study describes the duties of South American registered nurses (RNs), in light of existing federal laws regulating the professional practice of nursing

n The

law governing professional nursing, grants rights, defines the profession and its categories, functions, duties, powers, and provides legal support

n South

American RNs have legal autonomy to carry out prevailing management practices, nursing administration, and nursing care of greater complexity

n Nursing

is a profession that has gained rights and duties through legislation, legitimising the exercise of nurses’ professional skills

2013) Decreto Supremo n. 15.463 of 1978 (Government of Bolivia) s.1. http:// tinyurl.com/kowzegk (accessed 10 July 2013) Ley del Ejercicio Profesional de la Enfermería of 2005 (Government of Venezuela) s.1. http://tinyurl.com/p2uql35 (accessed 10 July 2013) Ley n. 19.536 of 1997 (Government of Chile) s.1. http://chile.justia.com/ nacionales/leyes/ley-n-19-536/gdoc/ (accessed 10 July 2013) Ley n. 24004 of 1991 (Government of Argentina) s.1. http://tinyurl.com/ o3febol (accessed 10 July 2013) Ley n. 266 of 1996 (Government of Colombia) s.1. http://tinyurl.com/ ov9u34b (accessed 10 July 2013) Ley n. 27669 of 2002 (Government of Peru) s.1. http://www.congreso. gob.pe/ntley/Imagenes/Leyes/27669.pdf (accessed 10 July 2013) Ley n. 57 of 1998 (Government of Ecuador) s.1. http://www. fenfermerasecuador.org/html/leyejercicio.html (accessed 10 July 2013) Ley n.18.815 of 2011 (Government of Uruguay) s. 1. http://www. parlamento.gub.uy/leyes/AccesoTextoLey.asp?Ley=18815&Anchor= (accessed 10 July 2013) Portaria n. 648 of 2006 (Ministry of Health of Brazil) s.1. http://dtr2001. saude.gov.br/sas/PORTARIAS/Port2006/GM/GM-648.htm (accessed 15 July 2015) Resolução n. 195 of 1997 (Federal Board of Nursing of Brazil) s.1. http://novo.portalcofen.gov.br/resoluo-cofen-1951997_4252. html?repeat=w3tc (accessed 15 July 2013) Resolución n. 118 of 2009 (Ministry of Health of Argentina) s.1. http:// tinyurl.com/nj3tjyz (accessed 10 July 2013)


LEGISLATION Decreto n. 11.381 of 2007 (Government of Paraguay) s. 3. http://tinyurl. com/ozq5pug (accessed 9 July 2013) Decreto n. 2.497 of 1993 (Government of Argentina) s. 1. http://www. alfinal.com/LEYES/decretoenfermeria.php (accessed 9 July 2013) Decreto n. 94.406 of 1987 (Government of Brazil) s.1. http://novo. portalcofen.gov.br/decreto-n-9440687_4173.html (accessed 15 July 2013) Decreto Reglamentorio n. 492 of 1999 (Government of Ecuador) s.1. http://tinyurl.com/k7mdchl (accessed 9 July 2013) Decreto Supremo n. 004 of 2002 (Government of Peru) s.1. ftp://ftp2. minsa.gob.pe/normaslegales/2002/DS004-2002.pdf (accessed 9 July

Key points


841


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Professional ethics as perceived by American nursing undergraduates.

SOSSUS Legal and Ethics Committee: summary report on professional liability.

Measuring professional nursing practice.

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Navigating legal issues in academic nursing.

Abortion: a legal and public health perspective.

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Professional responsibility: a perspective on the Bell Commission reforms.

Neutropenia: A nursing perspective.

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Professional liability insurance and the American psychiatrist.

Every Newborn: the professional organisations' perspective.

Apheresis nursing: a Canadian perspective.

Postpartum depression: a nursing perspective on women's health and behaviors.