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A report on the strong model in nursing profession

ABSTRACT The objective of this paper is to report the experience of implementing a model of advanced nursing practice that integrates a clinical nurse specialist into the nursing staff. The satisfaction of these users due to the closer relationship between the patient, family and clinical nurse in all stages of the caring process also stands out.

  1. October 22, 2012; Accepted.
  2. Scenario of the experience The perspective of offering children and adolescents with cancer the same treatment that is offered in developed countries motivated a group of doctors, nurses, businessmen, volunteers and representatives of the community to institute the GRAACC in the early 1990s, whose mission is to guarantee this population the right to achieve all chances of cure, with quality of life, by means of a treatment within the most advanced scientific standard 8. Ideally, it would also be a great service for preceptors to refer their preceptee charges for projects, committees, advancements, and honors within the professional practice environment and community, whenever possible.
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This mortality profile is similar to the mortality profile of developed countries 12. A study of the development of nursing in pediatric oncology shows that there is little documentation on the beginnings of this specialty, and its emergence is estimated to date to the late 1940s, when nursing care consisted basically of keeping the child clean, fed, comfortable and free of pain.

The opportunities for education and development were limited, and nurses acquired skills and competency through self-teaching and bedside training 3. This reality also applied to Brazil. Beginning in the 1960s, with the development of more efficient treatment strategies, in addition to advances in chemotherapy, infection control and pediatric intensive care, there was a substantial improvement in the survival of these patients.

This context fostered the development of an advanced pediatric nursing practice, which, in turn, had a significant influence on nursing in pediatric oncology 3. In the 1990s, a movement in nursing schools, aiming for the inclusion of oncology content in undergraduate courses, triggered the same reflection in the area of pediatric oncology 4. Currently, despite the supply of conventional specialization courses and the discipline of nursing residence in oncology, nurses continue to express the need for greater depth in topics related to the care of children and adolescents with cancer and their families.

  • In the perception of one CNS, for some doctors, nurses, nutritionists, social workers and physiotherapists, constant coping with the presence of the nurse, participating in the treatment together with the patient, has been seen as an invasion of their professional space;
  • As a result of this position and the growing demand in the different aspects involved in the line of care, the CNS has widened and incorporated new responsibilities, managing the care of this population together with the healthcare team;
  • Rio de Janeiro; 2012 [citado 2012 fev.

The combination of these facts has an impact on the profile of the nurses requested by the services, as well as on the structure of permanent educational programs that assist in the development of an advanced practice related to assistance, coaching, research and management in pediatric oncology 5.

The competencies include direct care; nursing consultation; system leadership; collaboration and cooperation with nursing staff and users; coaching; research; active participation in ethical and moral decision-making 7. METHOD To report the experience of the implementation of this model of advanced nursing practice, we have decided to describe the context in which it is being developed, the aspects of its planning and the experience of the action.

Scenario of the experience The perspective of offering children and adolescents with cancer the same treatment that is offered in developed countries motivated a group of doctors, nurses, businessmen, volunteers and representatives of the community to institute the GRAACC in the early 1990s, whose mission is to guarantee this population the right to achieve all chances of cure, with quality of life, by means of a treatment within the most advanced scientific standard 8.

The increasing demands of this population and the commitment to the idealized mission stimulated these professionals to seek a multiprofessional attendance model that would correspond to these needs and meet its particularities. Thus, it has organized its care procedures into pre-established protocols, with comprehensive care as a priority, but still focused on a report on the strong model in nursing profession time-sensitive needs that demand immediate resolution.

The constant demands generated by the complexity of the disease, its treatment and the repercussions for the individuals and their families have motivated nurses to rethink the current type of assistance and the expected competencies at the different levels of assistance offered in the institution.

Thus, the nurses responsible for planning, execution and evaluation of the care given to a determined group of patients, according to the type of neoplasia or therapeutic modality, were chosen for inclusion in an expanded, articulate and progressive view in the line of care, characterized as advanced nursing practice.

A new method of a report on the strong model in nursing profession work organization was chosen for adoption, which included the CNS in the composition of this team. The project was then implemented in March, 2010. The profile for the function of the CNS has ten requirements determined by the nurses of the institution: Among the activities intended for this sphere, the following stand out: In specific areas, such as bone marrow transplantation, the CNS participates in the execution of technical procedures related to the aspiration and infusion of bone marrow, umbilical cord blood and peripheral blood hematopoietic precursor cells, as well as in the evaluation of complications in transplant patients.

With respect to the nursing team, the CNS is responsible for teaching the protocols of treatment and specific nursing care. The CNS interacts with healthcare undergraduate and graduate students through lectures, internships and scientific events, putting childhood and adolescent cancer in Brazilian public health into context. Among the activities in this area, the following stand out: In the area of Researchthe topics of investigation emerge from matters arising from nursing practice in pediatric oncology.

In Managementthe activities of the CNS include the following: After defining this profile and the competencies for this function, the first areas to be considered with the CNSs were determined based on the needs for attendance in the current institutional scenario.

Subsequently, an announcement for the internal selection of nurses eligible for this position was made.

To participate in the selection process, the candidate would have to present documentation verifying the required profile and present a work project containing a proposal for action in the specified area, encompassing the four conceptual pillars designated for the CNS, for posterior evaluation by the created judging commission.

CALLING THE SHOTS

Experiencing and evaluating the action The area of EDEnf received the first CNS, followed by pain and palliative care; central nervous system tumors; bone tumors and retinoblastoma.

These CNSs have quickly become a reference in the institution for the follow-up of treatment of the above-mentioned populations. This position has demonstrated the need for the CNS to acquire new technical and scientific knowledge to better perform this function by incorporating specific knowledge. As a result of this position and the growing demand in the different aspects involved in the line of care, the CNS has widened and incorporated new responsibilities, managing the care of this population together with the healthcare team.

Strengthening the bond between the CNS, the patient and the family and sharing decisions on care with the other nursing and healthcare team members has rendered their activity more visible and pro-active, optimizing the planning and execution of caregiving actions. This appreciation has enabled the expansion of this model of nursing work organization to the areas of bone marrow transplantation; radiation therapy and diagnostic imaging; and leukemia a report on the strong model in nursing profession lymphoma during the period from 2011 to 2012, resulting in the current existence of eight CNSs.

Several factors have favored the implementation and development of this project, such as the philosophy of the institution and the nurses; the commitment of the group of CNSs; and the unrestricted support of the managers, clinical staff and nursing team.

These factors have enabled the advances in safe and qualitative care given to a clientele whose disease condition requires a highly qualified team to address the diversity and complexity of demands arising from the disease, the treatment and the rehabilitation and social reintegration process. Also as a result of this implementation, a further advance has been the participation and publication of works at scientific events, emerging from the needs of the daily professional practice, of individual authorship by the CNS or together with the multidisciplinary team.

In view of the innovative character of the proposal and the characteristic challenges of each project being implemented, there was a need for adjustments in diverse spheres of competencies of the CNSs, to meet, primarily, the demands from the areas of assistance and coaching. As a consequence of this decision, the activities envisioned for the spheres of competency related to research and management are still below expectations.

The search for a balance in the development of competencies in the four pillars proposed for the action of the CNS is the challenge being currently confronted. Another demonstrated challenge is the estrangement of some members of the healthcare team from this new proposal of action by the nurse.

In the perception of one CNS, for some doctors, nurses, nutritionists, social workers and physiotherapists, constant coping with the presence of the nurse, participating in the treatment together with the patient, has been seen as an invasion of their professional space. This situation has been overcome gradually by means of multiprofessional meetings discussing the specifics of action of each professional with regard to the demands of care for the population seen at the IOP and, especially, the aim to integrate the CNS into the nursing team work organization.

This strategy, linked to the positive evaluation of the received treatment, verbalized by patients and family members, has contributed to the resolution of this matter. For this purpose, a description was sought of the role of CNSs in the context of assistance, science, education and management.

Rio de Janeiro; 2012 [citado 2012 fev. Childhood cancer and pediatric oncologic care in Brazil: History, issues, and trends. Nursing care of the child with cancer. Permanent education in nursing in a university hospital.

Association of Pediatric Hematology, Oncology Nurses. Clinical Nurse Specialist Core Competencies: Manual de normas e rotinas de enfermagem. October 22, 2012; Accepted: May 24, 2013 Correspondence addressed to: