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Pensar Enfermagem / v.27 n.01 / August 2023
DOI: 10.56732/pensarenf.v27i1.218
Theoretical Article
How to cite this article: Santos J. Advanced Nursing: remembering the past, appreciating the present and
perspecting the future. Pensar Enf [Internet]. 2023 Aug; 27(1)84-91. Available from:
https://doi.org/10.56732/pensarenf.v27i1.218
Advanced Nursing: remembering the past,
appreciating the present and perspecting the future
Abstract
Introduction
This article arises from the analysis of care practice as a Nurse, in a sense of continuous
improvement. Thus, by understanding the professional history, the paradigms of the
profession and the positioning of Nursing in terms of society in today's world, it is possible
to envision possible paths for the profession.
Objective
This article aims to reflect on the historical evolution of Nursing in Portugal and to envision
the future of Portuguese Nursing in the light of international influences.
Development
The historical perspective and the implications in Nursing care practice, Person/Client-
Centred Care and the individualisation of the intervention and, finally, Advanced Nursing
and Advanced Practice Nursing were addressed. Analysing the historical perspective of
Nursing over the centuries, from its abnegated period, through the romantic era, medicine
and the technicist phase, we understand some current practices and doubts regarding the
perspective of the future. The development of knowledge and practice in Nursing should
go through the recognition and advancement of the core competencies of the discipline.
Conclusion
An approximation between scientific production and care practice is essential for the
development of Nursing. Facilitating this process is the development of the Nursing
specialties as a master's degree course, promoting not only different practices, but also the
critical look and thinking of professionals. In this process, the existence of other sciences
– health, social and human sciences, among others – that will promote the development of
the Nursing body should not be relegated to second place, but it is also crucial to
disseminate scientific production in Nursing, in order to give visibility to the science and
practice of the discipline.
Keywords
Nursing; History of Nursing; Person-centered Nursing; Advanced Practice Nursing.
João Santos1
orcid.org/0000-0003-0070-2451
1 Master. Rehabilitation Medicine Center of Alcoitão,
Lisbon, Portugal.
Corresponding author:
João Santos
E-mail: joao.santos.rn@gmail.com
Received: 02.12.2022
Accepted: 10.05.2023
Pensar Enfermagem / v.27 n.01 / August 2023 | 85
DOI: 10.56732/pensarenf.v27i1.218
Theoretical Article
Introduction
Care has existed since life came into existence: it is
necessary to 'care' for life so that it can remain. 1 ( p.117)
Nursing cannot be detached in its focus or in its history
from people. Looking back at the past, one can state that
Nursing and its development as an art and science is
intricately entwined with the care of Women. Women have
always played the role of carers within the family,
promoting the harmonious development of children,
ensuring the hygiene and maintenance of the
home/household, helping in the collection and preparation
of food, to name but a few. These responsibilities
embedded in the role of the Woman-Mother are still
present to this day, despite the significant social changes
that family and its representation are currently undergoing.
Historically, Women have had a less active social role until
the twentieth century – the century of wars. Despite this
social erasure, Women have not ceased to be a cornerstone
of society over the centuries, not only for their critical role
in the family – the structural and fundamental unit of
society – but also for their involvement in social, solidarity
and merciful causes. 2,3
Furthermore, the historical relationship between Nursing
and religion cannot be denied. In the case of Portugal,
Christianity, with its altruistic and fraternal basis, is
associated with caring for others. Looking at the works of
mercy spread by the Catholic Church, the seven corporal
works of mercy (to feed the hungry, to give drink to the
thirsty, to clothe the naked, to shelter the homeless, to visit
the sick, to visit the imprisoned and to bury the dead) and
the seven spiritual works of mercy (to instruct the ignorant,
to counsel the doubtful, to admonish the sinners, to bear
wrongs patiently, to forgive offences, to comfort the
afflicted, to pray for the living and the dead) are highlighted.
4 From the description of the works of mercy, it can be
stated that the fundamental values or principles of Nursing
are embedded in these religious principles. This intimate
relationship between Nursing and Religion was further
strengthened during the Middle Ages due to epidemics, war
and famine, which worsened social and health conditions.
In this regard, religion emerged as a safe haven for medieval
society, providing the necessary healthcare through the
intervention of religious orders. 5
Despite this role of religion in society, the expression of
this care in most cases was done by Women, involved in
the action of the religious orders of the time. Hence, one
can see the triad Nursing – Women – Religion, whose
pinnacle is assumed in Florence Nightingale – the mother
of modern Nursing. In the nineteenth century, during the
Crimean war, the lack of assistance conditions to the
military led Nightingale to reformulate and restructure the
existing conditions – hygiene and cleanliness, food,
ventilation, lighting, organization and separation of circuits
and spaces, among other things. This laboratory served as
a catapult to her contribution in modern healthcare. 5–7
This reflection arises following the analysis of everyday
practice as a Nurse, in a sense of continuous improvement.
Thus, by understanding the professional history, the
paradigms of the profession and the positioning of Nursing
in terms of society in today's world, it is possible to envision
possible paths for the profession. This article aims to reflect
on the historical evolution of Nursing in Portugal and to
envision the future of Portuguese Nursing in the light of
international influences. For its development, the abridged
historical path will be discussed: from Nightingale to the
biomedical model and the Nursing models – implications
for Nursing care practice; Person/Client-Centred Care and
the individualisation of the intervention; and Advanced
Nursing and Advanced Practice Nursing.
Formatted for holistic care since the beginning of training,
creating a distance from the biomedical model, focused on
signs and symptoms, professional practice was guided by
the individualisation of care. In this regard and in that of
competencies development, it became evident to rethink
professional practices to advance the Nursing care
provided in the transition phase from generalist nurse to
nurse specialist.
Abridged Historical Path: From Nightingale to the
Nursing Models – Implications for Nursing Care
Practice
The World Health Organization (WHO) defines health as
"not merely the absence of illness but a state of complete
physical, mental and social well-being"8. This mid twentieth
century definition of health attempts to encompass more
than the physical realm of health, i.e., the absence of illness,
originating in classical, mechanistic physics. This dualistic
view between health and illness can be at the root of the
biomedical model, focused on signs and symptoms -
objective, measurable aspects - and on the healing process.
9
The biomedical model guided Nursing training because of
the intimate professional and formative relationships
between the Doctor and the Nurse. According to this
model, Nursing care focuses on routines or tasks that meet
the physical needs of the patient. Following this line of
thought, the image of Nursing emerged as being
subordinate to Medicine, with the aim of curing or
controlling the illness, while the doctor was the main
person responsible for health care. 9
Returning to the influence of religion – Christianity – in
Nursing, the biomedical model came to add the values of
romanticism and pragmatism to Nursing. Embedded since
its genesis in asceticism, Nursing has always had a focus on
donations and total dedication to others. With scientific
evolution and the consolidation of the biomedical model,
subjugation to the doctor and the technicality of the
profession also became predominant in Nursing. With
these underlying conceptions, it can be stated that Nursing
86 | Santos, J.
Theoretical Article
lies between the care for the body, influenced by Medicine,
and the care for the spirit or soul, the result of religious
weight. 9
With Nightingale's revolution, Nursing added Science to its
Art
1
. The development of Nursing's own body of
knowledge can be said to have been initiated by
Nightingale's work.10 In the multidisciplinary context of
health, the influence that the various disciplines have
amongst each other cannot be ignored. In constant
development, Nursing's own body of knowledge, a
requirement for the definition of the profession and
discipline, undergoes mutations that develop Nursing
practice10,11 For Florence Nightingale, Nursing focuses on
caring for the person, rather than on the Nursing process,
the therapeutic relationship, or the Nurse. In this way,
Nursing shapes itself to meet the needs of each person. The
Nurse and the person being cared for are influenced by
environmental factors that should be addressed in order to
modify them so as to provide better care to the person
according to their needs. It was with Nightingale's work
that training in Nursing was developed, because according
to her perspective Nurses should have specific training and
instruction for their work, allowing for the improvement of
the care provided. 10,11
During the twentieth century, several conceptual models of
Nursing were developed. Pepin et al.10 classify Nursing
theory into five schools of thought:
− School of Needs: focused on situations of
dependence, Nursing supplements or
complements the person to meet fundamental
needs, promoting independence (Roper,
Henderson);
− School of Interaction: focused on the
interpersonal and therapeutic process between
the Nurse, the person and the context, in order to
facilitate the processes of transition and to
maximise health functionality (Peplau, King);
− School of Results: focused on the adaptation of
the person to the environment (internal or
external), promoting appropriate adaptive
responses (Roy, Neuman);
− School of the Unitary Human Being: focused on
the well-being of the person, maximising
individual health potential in every moment and
place (Newman, Rogers);
− School of Caring: focused on the
phenomenological process of sharing between the
Nurse and the person being cared for (Leinninger,
Watson).
1
For Hesbeen (43), to care is an art, a therapeutic art, (...) that will
enable you to help someone in their unique situation p.37).
Theoretical models in Nursing serve as a lens to look at and
understand the reality of Nursing care. In its conception,
there are four metaparadigm concepts that are the basis for
the theoretical model – Nursing, Person, Health and
Environment. Resulting from the influence of the current
paradigms, the various schools of thought in Nursing gave
body to the Science produced. 10
In the current Nursing care provided, it may be stated that
the holistic paradigm and holistic Nursing are guiding the
professional reality. Thus, Nursing encompasses the care of
individuals, families, groups and communities, ill or healthy and in all
environments. [...] It includes health promotion, illness prevention and
care for ill people, people with disabilities and people in the process of
dying. Protection, promotion of a safe environment, research,
participation in the formulation of health policies and in the
management of patients and health systems and education are also
important roles of Nursing. 12 In this regard, the person is much
more than a source of signs and symptoms, they have a
prior history and experience (culture, religion, spirituality,
relationships, among others) that influence the way of
being and interacting with others (in this case with the
Nurse). It is during this interaction that the Nurse
reinforces the existence and singularity of the person in the
illness process. 13,14
Person/Client-Centred Care and the Individualisation
of the Intervention
The Person-Centred Nursing Model reflects the ideals of
humanistic care, in which there is a moral component and
Nursing practice is based on a therapeutic intentionality,
which translates into relationships built upon effective
interpersonal relationships. 15 According to the model,
Nursing is an approach to the practice established through
the formation and promotion of therapeutic relationships,
based on respect for people; the individual right to self-
determination; and mutual respect and understanding,
through cultures of empowerment that promote
humanistic development15. According to McCormack &
McCance 15, Person-Centred Nursing is focused on 3 major
aspects:
− Nurses' competencies (professional
competencies, personal competencies,
commitment to work and personal traits);
− Organisational aspects (time, combination of
competencies and the role of the nurse);
− Client attributes.
In addition to the focus on technical competence, it is
extremely important to develop humanistic and holistic
care practices to embrace all forms of knowledge and action
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DOI: 10.56732/pensarenf.v27i1.218
Theoretical Article
to promote choice and partnership in care decision-making.
15
The middle-range theory of Person-Centred Nursing is
characterised by four fundamental aspects15,16:
− Pre-Requirements: these focus on the attributes
of the nurse and include being professionally
competent; having developed interpersonal skills,
self-knowledge; being committed to the job; being
able to demonstrate clarity of beliefs and values,
and knowing oneself;
− Care Environment: focuses on the context in
which care is delivered and includes an
appropriate mix of skills; systems that facilitate
shared decision-making; effective relationships
between staff members; a responsible sharing of
power; physical environment; supportive
organisational systems; potential for innovation
and risk-taking;
− Person-Centred Processes: focus on delivering
care through activities that operationalise person-
centred Nursing and include working with the
client's beliefs and values; sharing decision-
making; authentic engagement; empathetic
presence; holistic care delivery;
− Expected Outcomes: include a positive
experience with the care provided; involvement in
care/care giving; feeling of well-being; the
existence of a healthy culture.
Person-Centred Care develops from the communication
between the person and the professional. Therefore,
nurses' interventions should focus on listening to people's
narratives about their experience of falling ill, the personal
meaning they attach to the illness and the social restrictions
caused by suffering and symptoms. By understanding these
experiences, nurses can strengthen the person's
involvement in care decision-making. 17
When effective communication is established, interest is
shown in listening and the professional is available to
understand the person's perspective, this leads to greater
trust in the person, a caring environment is created in which
there is greater sharing of their feelings and greater
engagement in the decision-making process. 17
The person-centred model emphasises the meaningful
interaction between the nurse and the person. In this
aspect, McCormack & McCance15, when describing the
person-centred processes, describe the Engagement
2
as a
mirror of the quality of the nurse-person relationship.
According to the ability to jointly solve problems and/or
work together, the authors describe three levels: full
2
Free translation of the term Engagement described by
McCormack & McCance15).
engagement, partial disengagement, and complete
disengagement.
In the 2017 review, McCormack & McCance16 rename the
process to Engagement Authentically
3
. In its description,
Engagement Authentically is considered as the Nurse's
connection with the patient/person and family (or
significant others), determined by the person's knowledge,
clarity of beliefs and values, self-knowledge and
professional experience. This interaction between nurse
and person is unique, both for the individuals that comprise
it and for the moment in which it is established. Despite
this change, the authors maintain the levels of engagement
described previously.
By analysing the care practice, the presence of the
biomedical model is observed in the Nursing records.
Although the theoretical Nursing model adapted by the
institution is that of Roper, Logan and Tierney about
Activities of Daily Living, the Nursing records produced in
most situations give response/visibility to the tasks
performed, to symptomatic control, to continuous
improvement programmes and/or to the needs or
obligations of the directive/management component. In
terms of organisation and structure, the records are based
on the satisfaction of needs/activities of daily living.
However, the record on functionality is noted.
It is considered that the Nursing records document the care
provided, making it visible. Despite their importance, they
are sidelined in more complex or work overload situations.
18–20
Indeed, the above is in line with what is described by
Kärkkäinen et al. 21 Records often seem to reflect the tasks
performed by nurses, rather than personalised care. In
addition, there is reference to the way records are made,
which is recommended by the institutions, and which may
hinder the production of records focused on individualised
care. Hence, the content of Nursing records does not meet
comprehensive and person-centred criteria.
Furthermore, Kärkkäinen et al.21 consider that the visibility
of individualised care in Nursing records should take into
account the experience, needs and wishes of the people
being cared for and that care plans should be drawn up with
the person/patient and family. Although this cooperation
between nurse/person should exist, the documentation of
care should not be to exclude the technical knowledge of
the professional, the technology, the practice of care or the
ethical principles.
3
Free translation of the term Engagement Authentically
described by McCormack & McCance16).
88 | Santos, J.
Theoretical Article
Advanced Nursing and Advanced Practice Nursing in
the Portuguese reality
Nursing in Portugal underwent a great development in the
last century. This explosion occurred not only in its
effective care practice, associated with the evolution of
medical knowledge and the demands of the people cared
for regarding the care provided, but also in its training,
through the integration of Nursing as a higher education
course (baccalaureate and later undergraduate degree) and
the development of master's and doctoral degrees in
Nursing Science. 22
With the evolution in care practice, there was a need to
regulate the profession - the Regulamento do Exercício
Profissional dos Enfermeiros (Regulation for the
Professional Exercise of Nurses) was developed and the
Ordem dos Enfermeiros (Portuguese Order of Nurses) was
created. In the Regulamento do Exercício Profissional dos
Enfermeiros23, the nurse develops two types of
interventions: on the one hand, autonomous interventions,
initiated by the nurse's prescription and, on the other hand,
interdependent interventions, initiated by the prescription
of another health professional.
In some countries, due to difficulties in medical assistance,
the technical competencies of some nurses were developed,
making them legally qualified for diagnosis, therapeutic
prescription and prescription of complementary diagnostic
tests and their interpretation. This increase in nurses'
medical competencies led to the creation of the Nurse
Practitioner
4
. 22,24,25
According to the International Council of Nurses (ICN),
Nurse Practitioners "are generalist nurses who, after additional
education (master's degree for entry level), are autonomous clinicians".
26 In the national reality, this advance in Nursing practice
may be compared to the development of interdependent
competencies of nurses. Gardner et al.27 and Silva22 also
compared the Nurse Practitioner in their conception as a
hybrid model between doctor and nurse, based on the
biomedical model.
In light of this advancement in Nursing practice, it became
urgent to define the path to where it was intended to
develop the body, practice and science of Nursing. The
Canadian Nurses Association defined Advanced Practice
nurses as:
An umbrella term for registered Nurses and Nurse Practitioners who
integrate graduate nursing educational preparation with in-depth,
specialized clinical nursing knowledge and expertise in complex
4
The decision was made to keep the original/international
designation, as there is no equivalent in Portuguese
practice.
decision-making to meet the health needs of individuals, families,
groups, communities and populations. 28
These advanced practice nurses have the following
competencies: comprehensive/extended in the provision
of direct care; health systems optimisation;
education/training; research; leadership; and consultation
and collaboration. 28
More recently, the ICN has defined Advanced Practice
Nursing as:
Enhanced and expanded healthcare services and interventions
provided by nurses who, in an advanced capacity, influence clinical
outcomes and provide direct healthcare services to individuals, families
and communities26.
In the same document, the ICN defines the Clinical Nurse
Specialist
5
as a professional with advanced knowledge in
Nursing, beyond the knowledge developed in generalist or
specialty training, in making complex decisions in a specific
context, promoting quality and positively impacting the
health services. 26 This professional designation arises in
response to the development of the context of specialised
care practice, requiring further education beyond the
Nursing Speciality. Comparing with the Portuguese reality,
the acquisition of a Nursing Specialty by a Master's degree
– reference level for the attribution of the title of Clinical
Nurse Specialist26 – may be considered a path towards the
development, or rather, the advancement of the Portuguese
Nursing practice.
In this line of thought and in the national reality, Silva22
described Advanced Nursing as a development of
competencies in the area of caring and decision-making.
Thus, the development of masters and doctoral degrees in
Nursing has deepened the knowledge of human responses
to the care provided, but also developed nurses'
competencies for the effective delivery of care. 29 Within
the scope of nurse specialists, the Portuguese Order of
Nurses defined four domains of common competencies:
Professional, ethical and legal responsibility; Continuous
quality improvement; Care management; and Development
of professional learning. 30
With regard to the development of Nursing competencies,
Benner31 conceptualised it in five levels or phases, whereby
the phases of Proficient and Expert may be framed with
the competencies of nurse specialists. In her description,
the proficient nurse apprehends and understands care
situations as part of a life process, making decisions based
on the holistic model and learning and modelling
practice/decision-making with experience. Regarding the
5
The decision was made to keep the original/international
designation, as there is no equivalent in Portuguese
practice.
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DOI: 10.56732/pensarenf.v27i1.218
Theoretical Article
expert nurse, they support their action based on intuition,
thus having a high performance. 31
Comparing with the Strong Model of Advanced Practice,
27,32 it can be stated that the common competencies of the
nurse specialist meet the five areas of advanced practice,
with the provision of specialty care
6
corresponding to
Integral Direct Care
7
and the underlying processes of
advanced practice.
Conclusion
The principles of quality and safety in health are underlying
Lei de Bases de Saúde33 (Basic Healthcare Law). Nursing,
as a health science, seeks to answer to Quality and Safety in
health. 25
The WHO understands Quality in Health as a high degree
of professional excellence, with minimum risks, positive
health outcomes for patients and efficient use of available
resources. 34 Additionally, quality in health is considered as
a relationship between professionals and
patients/populations that aims at the best desirable health
outcomes according to current knowledge. 35
On the other hand, health Safety is more than "the
prevention of harm to patients". 35 For Mitchell36, patient
safety means the absence of preventable injuries and the
reduction of the risk of unnecessary harm associated with
healthcare to an acceptable minimum, based on current
knowledge, available resources and the context where the
care was provided, compared to the risk of non-treatment
or other treatments. This way, quality and safety in health
appear interconnected. This way, quality and safety in
health appear interconnected.
In the sense of professional excellence and in the
development of its body of knowledge as a science, it is
essential for Nursing
8
to focus on the increase of
competencies for person-centred performance – the
primary target of Nursing care. 22 Looking at the historical
evolution of Nursing and the current paradigm, it makes
sense to understand the middle-range theory of Person-
Centred Care. In the specific context of Rehabilitation, the
person-centred approach becomes a practice of excellence:
to approach the person in a holistic way, in order to solve
their daily difficulties, considering them as an expert in their
living experience; and emphasising the participation and
empowerment, respecting the person beyond the
impairment or ilness. 37
6
In accordance with the various Regulations of the
Specific Competencies of Nurse Specialists.
7
Free translation of Direct comprehensive care used in Mick &
Ackerman's model32.
In the reality of care giving, the main obstacles to person-
centred care are in line with those described by Moore et
al.38, namely traditional practices and structures, time
constraints and the documentation and organisation of the
institution. Furthermore, the lack of documentation
supporting person-centred care and the low visibility of the
actual care provided in the records emphasise the
difficulties in implementing this type of care.
The multidisciplinary intervention in health, not only of
several medical specialties, but also of several health
professionals, turns health care into a sea of interventions,
in which the person may sink. Therefore, by applying the
holistic paradigm to its practice, Nursing may be considered
a safe foundation, or rather a safe haven, from which,
alongside the person, strategies, processes, among others,
are developed to improve their health and reduce the
impact of their illness situation on their life path. 39
Despite the needs felt in other countries to include medical
competencies in nurses40, in Portugal the average number
of nurses is below the OECD41 average. In this sense, it
may be stated that, given the difficulty in providing Nursing
care to the population, the acquisition of extraprofessional
skills will not make sense. However, the literature highlights
that nurses with added competencies – Nurse Practitioners
– add value to the vision and provision of Nursing care to
the population. 24,27
In summary, analysing the historical perspective of Nursing
over the centuries, from its abnegated period, through the
romantic era
9
, medicine and the technicist phase, we
understand some current practices and doubts regarding
the perspective of the future. 9 Thus, the development of
knowledge and practice in Nursing should go through the
recognition and advancement of the core competencies of
the discipline. 22 An approximation between scientific
production – from the academic domain - and care practice
– from the community and hospital domain - is
fundamental for the development of Nursing. Facilitating
this process is the development of the Nursing specialty as
a master's degree course, promoting not only different
practices, but also the critical look and thinking of
professionals.29 In this process, the existence of other
sciences – health, social and human sciences, among others
– that will promote the development of the Nursing body
should not be relegated to second place, but it is also crucial
to disseminate scientific production in Nursing, in order to
give visibility to the science and practice of the discipline.
22,40,42
8
Nursing, that is, nurses in the delivery of care, teachers in
Nursing Schools and Nursing researchers.
9
Term used by Pearson & Vaughan9
90 | Santos, J.
Theoretical Article
Authors’ contributions
JS: Drafting the manuscript; Critical revision of the
manuscript.
Conflict of interests
The author declares no conflict of interest.
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