Skills certification

The Skills Certification presents two distinct periods of Nursing Tutelage Practice (PTE) which are: the EPT to obtain the title of Nurse and the Tutored Professional Development (DTP) that aims to obtain the title of Specialist Nurse [10]. These two distinct periods take place in a “Clinical Supervision Model” in a context of OE Accredited Formative Appropriateness, which validates competencies and their certification after EPT or DTP, i.e. there is a supervisory process (which includes the existence of OE certified clinical supervisors), the accreditation contexts where this practice takes place, and the existence of a structure responsible for executive aspects, thus ceasing to confer the professional title in a purely administrative manner, as currently verified [11]. EPT is designated by the Portuguese Council of Nursing as a “period of induction and transition to professional practice, supporting the gradual assumption of responsibility and autonomous intervention, safely for the professional and clients”, and its objective is “the transition from graduates to responsible nurses for general care” [12].

DTP period is defined as a “socialization period with a new (specialist) skills profile” which, in turn, also supports the gradual assumption of responsibilities and autonomous intervention, avoiding risks for both professionals and the target population [11]. According to OE proposal, it may last up to 36 months depending on the area of expertise [13].

Nurses initiation into a period of supervised performance does not change individual’s capacity as an autonomous agent for general care, as nurses already performed these functions by assuming professional responsibility for their decisions and acts, practiced or delegated within the scope of such general care. Then again, nurses’ acts practice based on clinical supervisor decision, nurses are responsible solely for the act, while the supervisor takes responsibility for the decision.

Specialty individualization system

The second pillar, SIECE, allows separation of different nursing specialties based on the structuring axis - target of intervention and the two organizing axes where we find health / disease processes and the environment that subsequently translate into different areas of specialization (Table 2) specifically: “Maternal, Obstetric and Gynaecological Health”, “Child and Youth Health”, “Adult Health”, Elderly Health”, “Mental Health”, “People in Critical Situation”, “Person in Chronic and Palliative”, “Rehabilitation”, “Family Health” and “Public Health” [9].

The SIECE is based on 9 criteria which are: Consistency, Specificity, Effectiveness, Relevance, Integrality, Exclusivity, Individualization, Sustainability and Autonomy, and 16 validation elements, which constitute the matrix of recognition of clinical specialties in nursing [14].

Formative suitability of clinical practice contexts

If until now the Nurse, achieving a Nursing Degree and the Specialization Course in Nursing, gathers a set of documents and presents them to OE who, in turn, issues the professional note, with MDP it is proposed that nurses frequent a period of supervised professional practice, which obeys parameters defined by OE and whose place of clinical practice also obeys quality parameters also defined by OE.

Thus, the determination of the “formative capacity”, in a context of nursing practice, depends on the prior guarantee of two processes under the responsibility of OE [10]:

• Accreditation of Formative Suitability of Clinical Practice Contexts

• Clinical Supervisor Competency Certification

When mentioned the terms Conditions of Formative Suitability of contexts, we refer to characteristics that each context must have and/or should have, so that they can provide quality nursing care and thus socialize professionals in appropriate contexts in a culture of care and professional development consistent with the profession’s benchmarks [10].

Therefore, it is proposed a framework for recognition of Formative Suitability that includes the requirements/suitability conditions applicable to the different contexts of nursing care in the organized National Health System. This is organized to allow different uses according to the specific nature of each context of clinical practice, the institution in which it is inserted and the purpose of accreditation [10].

To operationalize the framework, OE proposes: “A Framework for Recognition of the Formative Suitability of Clinical Practice Contexts” that is organized in different “Dimensions”, these in different “Criteria” and these in different “Indicators” [10].

Starting from the Nursing Care Quality Standards, the “Dimensions” to be considered in the process of accreditation of the formative suitability of clinical nursing practice contexts are defined, as follows [10]:

1. System of continuous improvement of nurses' professional quality;

2. Nursing information systems, organized around the systematization of the decision-making process;

3. Professional satisfaction of nurses;

4. Secure Nursing Appropriations;

5. Policy of continuing education of nurses;

6. Methodologies of nursing care organization.

Inside the criteria defined for the Assessment of the Formative Suitability of Clinical Practice Contexts is the existence of OE Certified Clinical Supervisors. One of the determinants of quality supervision, learning and development experience of supervised nurses is the quality of supervisors’ performance. Therefore, the need to select and train supervisors for the specific performance of this role is defended. Selecting according to certain criteria and training, according to a certain reference, for a competence profile. Within the criteria of selection of the supervisor should be valued also, training in the area of andragogy, experience in the area of ​​training, operation and management by the project model and scientific production in these areas [12].

As depicted in Figure 2 the Supervisor will have to have competencies that stem from the domain of “being a nurse”, meaning that, fit within the competence domain of the General Care Nurse and skills that can be fit into a specific domain of Clinical Supervision.

BENEFITS AND DRAWBACKS OF IMPLEMENTATION OF THE MODEL

Thinking about the benefits or drawbacks, strengths or weaknesses of MDP that has not yet been effectively implemented, is essentially based on experiences from other contexts and projections that are narrowly supported by high-level scientific evidence. In spite of this, some conclusions can be made about the model implementation (Figure 3) although not directed to the context of the specialist nurse, for the questions that need to be clarified, namely how nurses are paid during implementation period of DPT [7].

Considering nurses initiation, the implementation of this model will be beneficial by promoting evidence-based practice, enhancing critical thinking, and enabling the nurse to cope with theoretical and practical changes, minimizing stress and distress sometimes experienced, particularly in more complex situations, while protecting nurses from potential error and enabling them to develop their practice in a more supportive and self-reliant environment. In addition, in a context of unemployment, nurses may benefit from the model, although earning less than nurses’ pay is advantageous in view of the possibility of being unemployed [7,15].

Simultaneously, healthcare organizations, having certified and professional services supervised by others, will potentially increase their quality and satisfaction of their professionals, which means less cost (by reducing adverse events and increasing productivity of satisfied professionals). OE, as a regulatory entity, also benefits from the model implementation as it can regulate professional activity in a more focused and even manner [7].

From a macro point of view, society, to whom care is directed, will be favoured by this model, as benefits were pointed out, it will decrease the number of adverse events and mortality [7].

Drawbacks associated with MDP implementation are associated with direct or indirect costs. The former is imputed to health care organizations, the state and OE, while the latter are primarily to EPT nurses.

Healthcare organizations will incur costs (and expected return on investment) because, on one hand, they are professionally developing not productive nurses who are at the outset and who are paid (even if the value of the compensation is less than one experienced nurse and that the long-term gains from producing a competent nurse may be greater), on the other hand, are occupying the supervising nurses by devoting time to supervision, which also does not translate into immediate productivity for the institution. Despite this, the scientific evidence about the return on investment of institutions has yet to be more clearly demonstrated [7,16,17].

State Institution will incur costs associated with time spent by staff of Ministry of Health and Ministry of Education in EPT Management Structure. OE presents costs associated with maintaining a Competent Structure in operation, teams that visit clinical practice contexts during the accreditation process and teams responsible for the certification of clinical supervisors [7].

EPT nurses, given the possible centralization of clinical practice contexts, may have costs because they are displaced from their housing areas and may still have a lower salary input than they have, in the current form, in which they start their activity soon after the degree [7].

Looking at the whole scenario of the implementation of the MDP, one can expect a mostly positive impact with gains for the various stakeholders, with the ultimate beneficiary being highlighted: society. However, it is important to highlight the scarce evidence produced, either about this model in particular or about other programs such as nurses' internship (or residency) in other contexts [2,7,16].

Given this discussion of the model and the progress already made in its implementation, the question then arises why it has not yet been effectively implemented? On this subject the literature does not seem to provide a direct or obvious answer, however, by mobilizing critical thinking and contextualizing for the management discipline, one can mention possible obstacles to MDP implementation. Thus, while the constant need for adaptation and change is known to be professionally up to an increasingly demanding market, as well as the need for change to correct past failures and achieve learning and improvement, the difficulty in implementing it is also evident. changes and, in general, the difficulty of change.

Organization wise, the key role for change to take place is people, from which one expects flexibility, faster adaptation, value added in terms of quality and productivity, and responsiveness to the learning process either by the degree of innovation. The importance of change is related to the possibilities for growth, development, increased resources and, in general, to seize a moment that, if neglected, can have negative consequences. Leaders who are paralyzed in the change implementation process, who are unable to act efficiently and effectively by bringing an innovative idea (although not a recent idea in the model under consideration), to practice, can quickly become unable to do so [18,19].

Thus, obstacles pointed out are unemployment of recent graduates that induces them to settle on their own, to perform temporary duties in different places or to leave the country. Since the EPT period is not required in other countries, it allows a licensed nurse in Portugal to be able to practice nursing in another European country, but not in Portugal. However, access to tutored education seems to be limited as there is a lack of supervisors and certified contexts, with the exception of specialization difficulties, as there is usually one specialist nurse per service and two supervisors per context are required. In addition, some nurses refuse to add autonomy and responsibility inherent to the progression to a specialist nurse, allied to the controversy over the choice of a serial and non-selection exam [7].

For the implementation of this model and for the change of the current paradigm, health services will require accreditation of training contexts/certification of clinical supervisors, which will imply [11]:

• The existence of funds for this change in the services of the National Health System;

• The change of mindset, as this change presupposes demands for continuous improvement in the quality of health care provided to the population for safer and more effective care;

• A work of each professional and professional group, of involvement in continuous improvement practices;

• That health professional groups and the current political context can perceive the MDP as very positive for the development and recognition of the profession and nurses, with evident gains in better health care for the population.

CONCLUSION

In the last decades we have seen the evolution of the nursing profession in parallel with the evolution in teaching. In Portugal OE creation was crucial in this process. However, this development did not include the standardization of competences and, therefore, OE, as a regulatory body, advocates greater realization in nursing practice of this same regulation through the MDP. In this sense, it is proposed that the purely administrative attribution of academic degrees in Nursing should first obey a period of professional practice tutored in contexts of clinical practice also certified by OE.

In the current model, nurse requests OE to register for the attribution of the respective titles and, in this procedure, OE, as a regulator of the professional practice of Nursing, simply accepts the different academic backgrounds without any control and validation power, acting only in situations of knowledge of bad practices or in disciplinary situations. With MDP, OE assures society that it has all the competences to perform its inherent functions.

According to the original MDP, nurses' competency certification has two PTE processes: EPT and DPT. However, along with the course and framing of the nursing profession, there is an important milestone that questioned the whole model: the OE Statute was amended and the title of Licensed Nurse was obtained as an administrative procedure, i.e. EPT was removed.

It is also important to mention that MDP was the basis for a system of individualization of nursing specialties, giving rise to the emergence of ten areas of specialization. With this model Health Units acquire or not “training capacity” based on the achievement of accreditation of Formative Suitability and certification of competencies of Clinical Supervisors.

As expected, this new paradigm in nursing has drawbacks as well as benefits, with positive aspects being highlighted for the various actors: nurses, institutions and society. In general, the change based on this model brings greater regulation of clinical practice by the respective regulatory body of the profession, OE, providing greater control and knowledge of the contexts in which all nursing acts develop, allowing OE to ensure effectively to society greater safety and quality of nursing care.

In order for MDP implementation process to be completed, greater involvement of all stakeholders is recommended and as people are the biggest promoters of change, it is necessary to really inform and train about the MDP so that they can intervene in a meaningful way, aiming at improve the quality of services offered to the population and, thus, greater recognition of the class.

As already mentioned, there is no strong scientific evidence published on this subject and the studies of effective gains will be after the implementation of the MDP, so it was challenging to find relevant and current references on the subject, with several published documents coinciding with the beginning of the idea of implementation of this model, dating back to 2009.