Advanced Nursing Practices in the Care of People with Diabetes in Primary Health Care

Abstract

Objective  To analyze nursing care for people with diabetes mellitus from the perspective of Advanced Nursing Practices in Primary Health Care.

Methods  Cross-sectional and analytical study involving primary care nurses from four municipalities in a state in southern Brazil. An online instrument was used, based on national guidelines for diabetes care and the Modified Scale for Advanced Nursing Practices (EMDF/ANP), Brazilian version, using a score from 0 (I do not perform) to 4 (I always perform). The data were analyzed using the Statistical Package for the Social Sciences (SPSS).

Results  A total of 121 responses from primary care nurses were analyzed, with questions on 53 direct actions in the care of people with diabetes. Considering the average score, 4 items received a score between 0.0 and <1.0 (not performed), 6 items between 1.0 and <2.0 (incipient action), 19 items between 2.0 and <3.0 (action being developed), 23 items from 3.0 to 4.0 (established action). The items related to direct and comprehensive care had an average score of 2.78 (median 3). Nurses indicated the need for further training, especially in continuing education, and 91% agreed with the statement that Advanced Nursing Practices contribute to improving care for people with chronic conditions.

Conclusion  Nurses perform activities within the scope of Advanced Nursing Practices for people with diabetes, in their clinical aspects. It is essential to ensure their expanded scope of practice, organizational, social, and training strategies, also considering aspects of leadership, education, and research.

Diabetes mellitus; Nursing care; Advanced practice nursing; Primary health care

Resumo

Objetivo  Analisar os cuidados de enfermagem as pessoas com diabetes mellitus sob a perspectiva das Práticas Avançadas de Enfermagem na Atenção Primária à Saúde.

Métodos  Estudo transversal e analítico, com enfermeiros da Atenção Primária de quatro municípios de um estado do sul do Brasil. Utilizou-se instrumento on-line, baseado em diretrizes nacionais para o cuidado em diabetes e Escala Modificada de Delineamento para as Práticas Avançadas de Enfermagem (EMDF/EPA), versão brasileira, com utilização de escore de 0 (não realizo) a 4 (realizo sempre). Os dados foram analisados com o Statistical Package for the Social Science (SPSS).

Resultados  Foram analisadas 121 respostas de enfermeiros da Atenção Primária, sendo questionadas 53 ações diretas de atendimento a pessoas com diabetes. Considerando o escore médio, 04 itens receberam a pontuação entre 0,0 a <1,0 (não realiza), 06 itens entre 1,0 e < 2,0 (ação incipiente), 19 itens entre 2,0 e < 3,0 (ação sendo desenvolvida), 23 itens entre 3,0 e 4,0 (ação estabelecida). Os itens dos cuidados diretos e abrangentes apresentaram escore médio de 2,78 (mediana 3). Os enfermeiros sinalizaram a necessidade de maior formação, especialmente em educação permanente e, 91% concordam com a afirmação que as Práticas Avançadas de Enfermagem contribuem para melhoria do atendimento às pessoas com condições crônicas.

Conclusão  Os enfermeiros desempenham atividades dentro do escopo das Práticas Avançadas de Enfermagem para pessoas com diabetes, em seus aspectos clínicos. É fundamental assegurar seu escopo de atuação ampliado, estratégias organizacionais, sociais e de formação, contemplando também aspectos de liderança, educação e pesquisa.

Diabetes mellitus; Cuidados de enfermagem; Prática avançada de enfermagem; Atenção primária em saúde

Resumen

Objetivo  Analizar los cuidados de enfermería a las personas con diabetes mellitus desde la perspectiva de las Prácticas Avanzadas de Enfermería en la Atención Primaria de Salud.

Métodos  Estudio transversal y analítico, con profesionales de enfermería de atención primaria de cuatro municipios de un estado del sur de Brasil. Se utilizó un instrumento en línea, basado en las directrices nacionales para el cuidado de la diabetes y la Escala Modificada de Delineamiento para las Prácticas Avanzadas de Enfermería (EMDF/EPA), versión brasileña, con una puntuación de 0 (no lo hago) a 4 (lo hago siempre). Los datos se analizaron con el Statistical Package for the Social Sciences (SPSS).

Resultados  Se analizaron 121 respuestas de profesionales de enfermería de atención primaria, en las que se preguntaba por 53 acciones directas de atención a personas con diabetes. Teniendo en cuenta la puntuación media, 4 ítems recibieron una puntuación entre 0,0 y <1,0 (no se realiza), 6 ítems entre 1,0 y <2,0 (acción incipiente), 19 ítems entre 2,0 y <3,0 (acción en desarrollo) 23 ítems entre 3,0 y 4,0 (acción establecida). Los ítems de cuidados directos y integrales presentaron una puntuación media de 2,78 (mediana 3). Los profesionales de enfermería señalaron la necesidad de una mayor formación, especialmente en educación permanente, y el 91% está de acuerdo con la afirmación de que las Prácticas Avanzadas de Enfermería contribuyen a mejorar la atención a las personas con enfermedades crónicas.

Conclusión  Los profesionales de enfermería realizan actividades dentro del ámbito de las Prácticas Avanzadas de Enfermería para personas con diabetes, en sus aspectos clínicos. Es fundamental garantizar su ámbito de actuación ampliado, estrategias organizativas, sociales y de formación, contemplando también aspectos de liderazgo, educación e investigación.

Diabetes mellitus; Atención de enfermería; Enfermería de práctica avanzada; Atención primaria de salud

Résumé

Objectif Analyser les soins infirmiers prodigués aux personnes atteintes de diabète sucré dans la perspective des pratiques infirmières avancées en soins de santé primaires. Méthodes Étude transversale et analytique, menée auprès d’infirmiers de soins primaires dans quatre municipalités d’un État du sud du Brésil. Un outil en ligne a été utilisé, basé sur les directives nationales pour les soins du diabète et l’échelle de conception pour les pratiques infirmières avancées modifiée (EMDF/PIA), version brésilienne, avec une notation de 0 (je ne le fais pas) à 4 (je le fais toujours). Les données ont été analysées à l’aide du logiciel Statistical Package for the Social Sciences (SPSS). Résultats 121 réponses d’infirmiers de soins primaires ont été analysées, portant sur 53 actions directes de soins aux personnes atteintes de diabète. En considérant la note moyenne, 4 items ont reçu une note comprise entre 0,0 et < 1,0 (ne réalise pas), 6 items entre 1,0 et < 2,0 (action naissante), 19 items entre 2,0 et < 3,0 (action en cours de développement) 23 éléments entre 3,0 et 4,0 (action établie). Les éléments relatifs aux soins directs et complets ont obtenu un score moyen de 2,78 (médiane 3). Les infirmiers ont signalé la nécessité d’une formation plus approfondie, en particulier dans le domaine de la formation continue, et 91% d’entre eux sont d’accord avec l’affirmation selon laquelle les pratiques infirmières avancées contribuent à améliorer la prise en charge des personnes atteintes de maladies chroniques. Conclusion Les infirmiers exercent des activités relevant du champ des pratiques infirmières avancées pour les personnes atteintes de diabète, dans leurs aspects cliniques. Il est essentiel de garantir l’élargissement de leur champ d’action, les stratégies organisationnelles, sociales et de formation, en tenant également compte des aspects liés au leadership, à l’éducation et à la recherche.

Diabète sucré; Soins infirmiers; Pratique infirmière avancée; Soins de santé primaires

Introduction

Diabetes mellitus is a highly prevalent disease, with estimates reaching 643 million people worldwide by 2030. Brazil has 16.6 million cases, with a prevalence of 10.6% in the population aged 20 to 79, making it the 6^th country in the world with the highest number of cases.(¹)

About 90% of diabetes cases are type 2, associated with urbanization, aging, physical inactivity, and obesity. In Brazil, it is estimated that 31.9% of cases are underdiagnosed, ranking 9th in the world in this classification. For type 1 diabetes (0 to 19 years old), the country ranks 4th, with 99,000 people in this age group and 499,000 among all ages.(¹)

Since 2014, the Pan American Health Organization (PAHO) has been promoting Universal Health Coverage (UHC) to expand access to healthcare. Among its strategies, Advanced Nursing Practices (ANP) in Latin America stand out. In 2018, a document was published on the expansion of nurses’ role in Primary Health Care (PHC), addressing competencies and implementation strategies.(²-³)

Brazil has the Unified Health System (SUS), a universal system that recognizes health as a right. Unlike Universal Health Coverage, which is limited to contracted coverage, the SUS seeks to provide comprehensive access.(⁴)However, challenges remain, such as high demand, gaps in care, lack of professionals and infrastructure, and limitations in screening and timely treatment, indicating the need for new approaches to health care.(⁵)

With regard to ANPs, there are differences between countries, but basically they are referred to as direct care nurses (ECD), called Nurse Practitioners (NP), who are professionals who work in a generalist capacity, linked to direct care, and clinical specialist nurses (ECE), who work in specialized areas of health.(⁶-⁸) The International Council of Nurses (ICN) recommends that there be legislation to confer, protect, and recognize the title of ANP, and that the regulatory mechanism be explicit and able to sustain them.(⁷)

The scope of actions includes the authority to prescribe medications; request laboratory tests, imaging, or devices that require official requests; indicate and decide on treatments and therapies; perform diagnoses or advanced health assessments: ability to perform clinical diagnoses, differential diagnoses, diagnosis of side effects, and disease staging; responsibility for a group of users; referring and back-referring individuals, including predicting hospital admissions and discharges, and being the first point of contact with the user.

In countries where ANPs are established, four main trends have emerged, such as: the development of specific functions in the interface with traditional health professionals; different clinical functions that did not exist previously, such as monitoring chronic conditions, supporting care pathways, liaison functions, or case management; increased focus on educational programs for nurse training and specific training. Many countries have had to adapt regulations to expand the prescription of pharmaceutical products by nurses.

In the care of people with diabetes, care is based on PHC through NP and, in other countries, on nurses specializing in diabetes to provide care, monitoring, and support for self-management of the chronic condition.(⁹,¹⁰)

Considering the prevalence of diabetes in Brazil, the fact that this condition is directly assisted by PHC teams, and the mobilization of the WHO and PAHO for the establishment of ANPs, the objective of this study was to analyze direct nursing care for people with diabetes mellitus from the perspective of Advanced Nursing Practices in Primary Care.

Our hypothesis is that the adoption of Advanced Nursing Practice, especially direct care, in the monitoring of people with Diabetes Mellitus, favors the expansion of access and timely care to services, providing comprehensive and continuous care, control, and reduction of acute and chronic complications resulting from the disease.

Methods

A cross-sectional and analytical study was conducted with PHC nurses from four municipal health departments, representing a macro-region of health in a state in southern Brazil.

An instrument was developed based on: 1) Clinical Protocol and Therapeutic Guidelines (PCDT) of the Ministry of Health; 2) Santa Catarina Guidelines; 3) Nursing consultation protocol no. 1; 4) Manual for nursing consultation in PHC for people with diabetes; 5) Resolution of the Federal Nursing Council (COFEN) on the activities of nurses in diabetes care and education; and 6) Modified Scale for Advanced Nursing Practices (EMDF/ANP), Brazilian version.(¹¹-¹⁶)

The instrument totaled 54 actions to be performed by nurses in the individual interest of the patient, focusing on specific needs (Table 1). These are direct activities, such as procedures, assessments, data interpretation, physical care, and guidance. The items were evaluated using a 5-point Likert scale, from 0 to 4, with 0 being I do not perform, 1 being rarely, somewhat frequently (2), very frequently (3), and always (4), following the EMDF/ANP Scale model, i.e., the closer to the maximum score, the greater the time dedicated to the activity, considering the average score of two as indicative of ANP.(¹⁶)

Table 1
List of categories/actions performed by primary health care nurses in the care of people with diabetes

Category/action	Total	Median	p-value
	Mean (SD)	P50 [P25; P75]
Screening actions
1. Performs screening for DM with own instrument (Findrisk or other)	1.31 (1.33)	1 [0; 2]	0.224
2. Performs cardiovascular risk stratification	1.73 (1.34)	2 [0; 3]	0.453
3. Performs diabetes risk stratification	1.42 (1.23)	1 [0; 2]	0.95
Nursing consultation
4. Performs nursing diagnosis	2.52 (1.26)	3 [2; 3]	0.592
5. Checks vital signs during consultation	3.54 (0.77)	4 [3; 4]	0.843
6. Provides guidance on the medication regimen	3.31 (0.86)	4 [3; 4]	0.481
Expansion of clinical activities
7. Performs clinical diagnoses	1.77 (1.38)	2 [0; 3]	0.318
8. Prescribes medications	0.97 (1.35)	0 [0; 2]	0.021
9. Renews prescriptions for medications to continue DM treatment	0.73 (1.32)	0 [0; 1]	<0.001
10. Checks and provides guidance on general and targeted immunization for people with DM	3.10 (1.09)	3 [3; 4]	0.286
11. Performs physical examinations focused on DM-related demands.	3.05 (1.01)	3 [2; 4]	0.032
12. Lipoatrophy and/or lipohypertrophy	1.43 (1.43)	1 [0; 3]	0.102
13. Other dermatological changes	2.02 (1.32)	2 [1; 3]	0.418
14. Changes in elimination (neurogenic bladder, gastroparesis, candidiasis)	2.29 (1.21)	2 [2; 3]	0.324
15. Changes related to sexuality (changes in libido, erectile dysfunction)	2.02 (1.21)	2 [1; 3]	0.775
16. Foot examination	2.60 (1.19)	3 [2; 4]	0.005
17. Referral for dental examination	2.02 (1.28)	2 [1; 3]	0.247
18. Performs or refers for screening for complications	2.86 (1.04)	3 [2; 4]	0.206
19. Performs/supervises dressings for people with lower limb injuries associated with DM	3.42 (0.79)	4 [3; 4]	0.299
20. Provides guidance on lifestyle changes	3.75 (0.60)	4 [4; 4]	0.156
21. Nutrition	3.76 (0.58)	4 [4; 4]	0.117
22. Physical activity	3.74 (0.58)	4 [4; 4]	0.154
23. Smoking	3.65 (0.70)	4 [4; 4]	0.194
24. Provides guidance on insulin therapy	3.43 (0.89)	4 [3; 4]	0.601
25. Preparation, dosage, and method of application	3.39 (0.93)	4 [3; 4]	0.887
26. Rotation of locations	3.45 (0.88)	4 [3; 4]	0.838
27. Storage (in use, in stock, shelf life after opening, transport)	3.38 (0.98)	4 [3; 4]	0.794
28. Waste disposal	3.41 (0.97)	4 [3; 4]	0.569
Glucose monitoring, hypo- and hyperglycemia
29. Defines and evaluates glucose monitoring	3.12 (1.01)	3 [3; 4]	0.256
30. Explains and demonstrates the technologies that the person can use to optimize their treatment (glucometer, insulin pens, apps, carbohydrate counting, etc.)	3.03 (1.12)	3 [3; 4]	0.029
Diabetes education for self-care
31. Questions about understanding and adherence to treatment	3.44 (0.76)	4 [3; 4]	0.962
32. Questions about the difficulties the person is facing in their self-care	3.39 (0.80)	4 [3; 4]	0.837
33. Explains and demonstrates the care required to maintain care	3.34 (0.86)	4 [3; 4]	0.635
Person-centered care
34. Develops a person-centered treatment plan	2.38 (1.21)	3 [2; 3]	0.847
35. Does it coordinate care with other services/professionals?	2.80 (1.11)	3 [2; 4]	0.535
36. Applies integrative and complementary practices	1.40 (1.54)	1 [0; 3]	0.549
Navigating the healthcare network
37. Refers patients to specialized services.	2.31 (1.60)	3 [1; 4]	0.118
38. Provides telecare in DM	0.89 (1.36)	0 [0; 2]	0.592
39. Performs teleconsulting (via Telessaúde SC) for case discussion and decision-making in clinical practice?	0.60 (1.17)	0 [0; 1]	0.725
EMDF/ANP Domain 1 - Direct and comprehensive care .(16)
40. Performs and documents the patient’s medical history and physical examination	3.02 (1.11)	3 [3; 4]	0.129
41. Assesses psychosocial, cultural, and religious factors that interfere with patients’ needs	2.74 (1.15)	3 [2; 4]	0.447
42. Requests and interprets diagnostic tests	3.03 (1.11)	3 [3; 4]	0.028
43. Gathers and interprets assessment data to formulate a care plan	2.78 (1.16)	3 [2; 4]	0.879
44. Performs specific care and procedures	2.98 (1.06)	3 [3; 4]	0.227
45. Assesses patient/family response to proposed treatment and modifies care plan according to response	2.56 (1.14)	3 [2; 3]	0.794
46. Provides guidance to family members and/or caregivers	3.16 (0.87)	3 [3; 4]	0.306
47. Promotes health education activities (counseling, care development, and autonomy) for patients/families	2.60 (1.23)	3 [2; 4]	0.253
48. Documents appropriately in the patient’s medical record	3.44 (0.82)	4 [3; 4]	0.073
49. Acts as a consultant (specialized guidance in PHC) in improving patient care and nursing practice based on expertise in the area of specialization	1.71 (1.49)	2 [0; 3]	0.646
50. Simplifies the ethical decision-making process in patient care	2.94 (1.08)	3 [2; 4]	0.842
51. Coordinates interdisciplinary/interprofessional plan for patient care	2.08 (1.27)	2 [1; 3]	0.96
52. Collaborates with other services to optimize patient health status	2.93 (1.00)	3 [2; 4]	0.298
53. Facilitates patient flow between different points in the healthcare network	2.99 (1.02)	3 [2; 4]	0.059
Calculation of domain	2.78	3 [2; 4]

• Caption: 0.00 to < 1.0 1.00 and < 2.00. 2.00 and < 3.00. < 3.00 Statistical significance.

The EMDF/ANP Scale has five domains, but because the research was directed at direct care with a focus on diabetes, only domain 1, related to direct and comprehensive care, was used.(¹⁶)

The actions were grouped into: screening actions, aspects of nursing consultation, expansion of clinical activities, immunization, targeted physical examination, screening for complications, guidance on insulinization, glycemic monitoring, technologies, self-care education, person-centered care, network navigation, and domain 1 - EMDF/ANP.(¹⁶)

The collection instrument was validated by nurses from a chronic conditions research group and adjusted.

All nurses from PHC services in the selected municipalities were invited to participate, including those who had been working for more than six months and excluding incomplete or duplicate responses or those from professionals not directly linked to these locations.

Data collection took place between December 2023 and June 2024, through contact with service management and various dissemination strategies, such as face-to-face meetings, emails, dissemination in groups, and direct contact.

The nurses who agreed to participate accessed the Free and Informed Consent Form (FICF) through the link available in the dissemination material and then answered the questionnaire via Google Forms. The link allowed completion by cell phone or computer and was linked to the registered email and the participant’s initials to avoid duplication.

The collection consisted of sociodemographic characterization (age, gender, length and type of training, work characteristics, and others), questions directly related to the practice of nursing care for people with diabetes, and understanding of ANPs.

After data collection was completed, an audit was performed that excluded two duplicate questionnaires and three from professionals outside the selected units.

The data are presented with cut-off values of 0.0 to <1.0 (not performed), 1.0 to < 2.0 (incipient action), 2.0 to < 3.0 (action being developed), and 3.0 to 4.0 (established action). Items with statistical significance between them are highlighted separately with values for each municipality, with mean, standard deviation, and median.

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 25 for Windows, with a significance level of 0.05. The proportions of the variables were compared between municipalities using the chi-square test, with standardized residual analysis (≥1.96) when significant. In addition, the Kruskal-Wallis test was used to compare the distributions of the items, with different letters assigned to indicate statistical differences between municipalities.

Categorical variables were represented by absolute and relative frequency. Variables D12 to D15, D17, D21, and D23 could be answered by more than one response per respondent. Thus, a thematic analysis of multiple responses was performed.

The research followed the precepts of the National Health Council, with the approval of the research by the Ethics Committee of the Federal University of Santa Catarina and registered with CONEP - CAAE: 71702523.2.0000.0121, opinion no. 6.462.297. The municipalities surveyed will be identified as A, B, C, and D.

Results

There were 121 valid responses among PHC nurses in the municipalities, representing 50% of the total number of nurses, distributed as follows: municipality A 40.1% (71), municipality B 74.1% (20), municipality C 76.9% (20), municipality D 90.9% (10), and a direct refusal rate of 0.03%.

The nurses were between 31 and 50 years old (81.8%), were female (91.7%), and identified themselves as white (82.6%) or brown (13.2%). They had a lato sensu specialization (81.6%), with 48.7% in PHC, Family Health, or Collective Health, and 4.9% had a strictu sensu specialization. Access to updates in PHC/FHS (99.2%) and nursing (98.3%) occurred mainly through digital means (99.2%), being carried out at home and at work (49.6%).

The length of service in PHC was over 10 years (43.8%), but 11.6% had been working for less than 1 year, and 77.7% of the professionals were tenured public employees. Sources of updating included government agencies (35%), digital media (22%), scientific societies (21%), books (9%), and scientific articles (1.2%). In the last two years, 34.4% participated in training on PHC, 42.7% on nursing practice, and 23.4% on diabetes.

The protocols cited proportionally were the PCDT of the Ministry of Health (79-88.2%), the nursing protocol of COREN/SC (61.9%-95%), and the state guidelines (33.3%-48%). Institutional protocols were mentioned by 55% in municipality A and 100% in municipality D.(⁹-¹¹)

Most worked in the Family Health Strategy (76.9%) with a 40-hour work week (98.3%). Although the team was complete for 53.9%, other teams lacked professionals such as Community Health Agents (40%) and dental surgeons (16.4%). Working conditions were considered good or very good by 69.4%, with positive impacts from the relationship with the team (22%) and community (21.5%) and negative impacts from the physical facilities (29.9%) and human resources (20.7%).

In 71.2% of cases, there was a specific professional for unit management, with significant variation (p < 0.001) between municipalities. Many nurses accumulated care and coordination functions, spending between 17 and 40 hours per week on care.

The nursing consultation time varied between 15 and 45 minutes, with 78.6% between 15 and 30 minutes. Municipality C stood out with longer consultations, between 30 and 45 minutes (64.3%).

Of the 54 actions in the instrument, one was excluded due to similarity, leaving 53 items. To improve visualization, the data were classified by color coding, highlighting the results of the statistical analysis, presented in Table 1. The data that showed statistical significance among the municipalities evaluated are shown in Table 2.

Table 2
List of categories/actions performed by primary health care nurses in the care of people with diabetes that showed a statistically significant difference between the municipalities studied

Category/action	Mean	Median	Municipality A	Municipality A Md	Municipality B	Municipality B Md	Municipality C	Municipality C Md	Municipality D	Municipality D Md	p-value
	(Standard Deviation)	P50 [P25; P75]	Mean (SD)	P50 [P25; P75]	Mean (SD)	P50 [P25; P75]	Mean (SD)	P50 [P25; P75]	Mean (SD)	P50 [P25; P75]
Expansion of clinical activities
Prescribes medications	0.97 (1.35)	0 [0; 2	0.70b (1.30)	0.00b (0.00)	1.55a (1.15)	2 [1; 2]	1.53ab (1.47)	1 [0; 3]	0.60ab (1.35)	0 [0; 0]	0.021
Renews prescriptions for medications to continue treatment of DM	0.73 (1.32)	0 [0; 1]	0.32b (1.00)	0.00b (0.00)	1.65a (1.39)	2 [1; 3]	1.47ac (1.61)	1 [0; 3]	0.40bc (1.26)	0 [0; 0]	<0.001
Requests and interprets diagnostic tests	3.03 (1.11)	3 [3; 4]	3.15a (1.06)	3.00a (3.00)	3.40a (0.68)	4 [3; 4]	2.37b (1.38)	3 [1; 3]	2.70ab (1.16)	3 [2; 4]	0.028
Explains and demonstrates the technologies that people can use to optimize their treatment (insulin pens, app, glucometer, CHO counting)	3.03 (1.12)	3 [3; 4]	3.31b (0.92)	4.00 (3.00)	2.65a (1.23)	3 [1; 4]	2.50ab (1.32)	3 [1; 4]	2.90ab (1.29)	3 [2; 4]	0.029
Performs physical examination focused on DM-related demands	3.05 (1.01)	3 [2; 4]	3.13b (1.00)	3.00b (3.00)	2.90b (1.02)	3 [2; 4]	3.30b (0.86)	4 [3; 4]	2.30ab (1.06)	3 [1; 3]	0.032
Foot examination	2.60 (1.19)	3 [2; 4]	2.58a (1.17)	3.00 (2.00)	2.30a (1.13)	2 [2; 3]	3.30a (1.08)	4 [3; 4]	2.00b (1.25)	2 [1; 3]	0.005

• Caption: 0.00 to < 1.0 1.00 and < 2.00. 2.00 and < 3.00. < 3.00 Statistical significance.

Integrative and Complementary Practices (ICPs) were not performed or recommended by 43.8% of nurses, while 27.3% frequently indicated them, such as: auriculotherapy 47.5%, acupuncture 21%, phytotherapy 16.8%, homeopathy 12.4%, and moxibustion 1.5%. The indications were related to emotional balance (32.4%), relief of chronic pain (23.5%) and anxiety (20.6%), wound healing (10.8%), and other clinical problems. Regarding the self-assessment of the nursing consultation, 53.7% considered it satisfactory, 34.7% very good, 7.4% fair, and 2.5% excellent. However, 96.8% recognized the need to improve professional training. To expand diabetes care, 77.7% suggested continuing education, followed by courses of up to 60 hours (52.9%), on-the-job training (49.6%), specialization (18.2%), master’s degree (5%), and doctorate (4.1%). Regarding the adoption of ANP for people with chronic conditions, 50% agreed, 41% strongly agreed, and 9% were neutral, with no disagreement recorded. Chart 1 presents the understanding and perceptions of nurses, demonstrating agreement with the topic when addressing the facilities and difficulties in implementing ANP.

Chart 1
Distribution of nurses’ responses regarding knowledge and perceptions about ANP

.	.
1. Nurses’ perceptions of advanced nursing practice actions that can be developed autonomously.	n(%)
Research activities, mainly focused on evidence-based practices, focused on clinical practice.	64(52.9)
Authority to perform clinical diagnoses, diagnostic investigations, and prescribe medications and therapies.	62(51.2)
Providing care for acute and chronic health needs.	55(45.5)
Referral to other professionals and services.	53(43.8)
Lead health teams.	48(39.7)
Coordinate the clinical management of complex cases.	43(35.5)
Be responsible for a specific population, serving as their primary healthcare contact.	42(34.7)
Possibility of performing hospital admissions and discharges or other services.	08(6.6)
All of the above options.	23(19)
None of the options.	02(1.7)
2. Nurses’ assessment of the ease of implementing ANPs.	n(%)
Opportunity to strengthen nurses’ autonomy.	82(67.8)
Coordination of the nursing profession in the discussion and implementation of Advanced Nursing Practices.	66(54.5)
Creation of specific regulations and remuneration.	56(46.3)
Coordination of actions between national entities such as ABEN, COREN, Ministry of Health, and international entities such as PAHO.	55(45.5)
Nurses should be included in all primary health care teams and specialized teams.	54(44.6)
Acceptance by the population of being cared for by Advanced Practice Nurses.	52(43.0)
The law governing the professional practice of nursing already covers some of these actions.	49(40.5)
I do not agree with any of the above options.	02(1.7)
3. Nurses’ perceptions of the difficulties in implementing ANPs.	n(%)
Lack of specific regulations and remuneration.	80(66.1)
Resistance from other professional categories, such as doctors.	79(65.3)
Additional workload for nurses.	74(61.2)
Resistance of the population to being treated by Advanced Practice Nurses.	53(43.8)
Need for change in nurse training.	52(43.0)
Understanding among the nursing profession that these actions are not part of the profession.	31(25.6)
I do not agree with any of the above options.	02(1.7)

The open questions were answered by 22% of respondents, who reinforced topics such as the use of new technologies, advances in digital health and telecare, longer consultation times, reduced bureaucracy, improved remuneration, professional recognition, empathetic approaches, development of soft skills, and creation of referral centers for people with diabetes.

Discussion

To analyze the nursing care provided to people with diabetes, it is necessary to point out that the municipalities surveyed are geographically close to each other, but have important differences in terms of size, healthcare network, and organization of practices.

Service management varies between municipalities, with different administrative models. In one, there is a unit manager, in another a district manager, and in others, nurses accumulate care and administrative functions, reducing care time and potentially generating overload. However, there was no direct relationship between exclusive management and consultation duration, with the longest consultations reported by nurses who perform both functions.(¹⁷-¹⁹)

Directly, in the context of expanding the scope of nurses, the COREN/SC protocol for nursing consultations was implemented differently until the date of the research: in municipality B since 2018, in C from 2023, partially in municipalities A and D, with restrictions on the renewal of medications.(¹³)

Considering that the role of ANPs and PHC is linked to the NP, the actions outlined by the American Diabetes Association in the Diabetes Ready Reference for Nurse Practitioners directly permeated the analysis.(²⁰)

Regarding diagnostic criteria, actions related to screening for diabetes, cardiovascular risk, and risk stratification in diabetes,(¹⁴,¹⁵)are incipient activities within the scope of nursing, despite PHC being the gateway to the system, and this approach involves the entire healthcare team, not being exclusive to this professional.(¹¹-¹²,¹⁷,²⁰)

The expansion of the clinical scope, including diagnoses and prescriptions, is still limited, despite being provided for in protocols. Its implementation requires targeted academic training, organization, management support, and effective communication with the community to expand its reach.

The municipalities that have adhered to the COREN/SC protocols, where nurses have received training, have expanded direct care actions. Municipality B, with the longest period of adherence and consistency, has better indicators. The commitment of management and political institutions was fundamental to the success of this change in the healthcare network.(¹²,²⁴)

In this study, the nursing consultation includes nursing diagnosis, vital signs, glycemic monitoring, knowledge and guidance on oral medication regimens, procedures related to insulinization, specific physical examination, skin and foot care, nutritional guidance, exercise and physical activity, smoking, immunizations, management of lower limb injuries, referral or screening for macrovascular and microvascular complications.(¹⁴,²⁰,²²,²⁵)

Regarding physical examination, inspection for lipodystrophy and hypertrophy is insufficient, and there are differences in relation to foot examination. Municipality C stood out, highlighting the value of nursing consultations in preventing amputations and strengthening therapeutic adherence.(¹⁴, ²⁶-²⁷)

Diabetes education activities focus on self-care, providing guidance on the use of technologies, maintenance of treatment, adherence, and challenges faced. Telehealth services provided by nurses for diabetes are still uncommon, despite advances in the literature on care and education strategies for people with diabetes.(²⁸-³⁰)

Navigation in the care network highlights referrals to specialized services, usually restricted to physicians, with some services allowing referrals to other nurses or multidisciplinary teams. Teleconsulting is also not a common practice for nurses via Telehealth, which is used by physicians to regulate access and provide second clinical opinions. However, the COREN/SC protocol allows PHC nurses to refer people with diabetes to an ophthalmologist. The current structure limits its use, requiring revision due to the expansion of the nurses’ clinical scope.(¹³, ³¹)

Person-centered care is the main approach for people with diabetes, with nurses participating in the coordination of care and development of the therapeutic plan.(²⁸) ICPs are alternatives for holistic care, although they are not widely used by nurses. When applied, they address issues such as mental health, chronic pain, and other conditions. Initiatives such as the map of scientific evidence on Traditional, Complementary, and Integrative Medicines assist in this process by analyzing nine therapies and their effects.(³²)

The direct domain of EMDF/ANP revealed advanced nursing practices in PHC, with an average score per item of 2.78 and a median of 3 [2; 4], highlighting adequate records, with the development of actions directly linked to the comprehensiveness and coordination of care. The lowest scores were in consulting for improving the quality of care and in nursing practice based on expertise in their area of activity. One hypothesis for this response would be the understanding that primary care is not an area of specialization. The interpretation of tests showed higher performance in municipalities A and B, reflecting organizational differences.(¹⁶)

Although 91% of respondents recognize the impact of ANPs on care, their scope still needs to be further explored and discussed among nurses. Greater autonomy and professional coordination are seen as strengths for implementation, while resistance from other categories, regulation, remuneration, and overload are challenges, as in other countries.(⁷, ⁹)

Most nurses, even with a favorable self-perception of their care, recognize the need for continuing education. They highlight continuing education and the positive impact of ANPs on care. Countries such as Canada and England, where ANP exists, have robust professional associations that support training, regulation, and professional clinical updating.(³³,³⁴)

In PHC, in addition to NPs, nurses trained in diabetes are integrated into teams or care for patients in multidisciplinary community education groups. In some countries, such as Canada, medical directives expand the scope of nurses (RNs), increasing their autonomy.(³³,³⁵)

This study investigates the role of ANP in PHC with a focus on people with diabetes, a topic that has not been addressed in Brazil, and identifies approaches to expand access and ensure comprehensive and continuous care.

The limitations of the study include the lack of depth in clinical outcomes in direct care, the fact that the volume of care and waiting times for appointments were not evaluated, and its limitation to a specific geographical region.

Proposal for new studies, such as the design of a list of practices for primary care nurses in diabetes care in Brazil with an expanded scope, training proposals, and clinical outcome studies.

Conclusion

The research achieved its objective by understanding the nursing care provided to people with diabetes mellitus and its relationship with advanced nursing practices, focusing on clinical practice. Nurses perform direct care activities within the scope of advanced practices. ANPs involve leadership, education, and research, but clinical activities directly impact people’s access to PHC. It should be noted that even in countries where ANP has been implemented, nurses maintain their usual functions, and working as an ANP requires specific training, with a significant commitment to the qualification process. This role also requires a solid legal, social, and organizational framework to be properly recognized and exercised, with protection and guarantees for its maintenance.

Acknowledgments

To the Coordination for the Improvement of Higher Education Personnel (CAPES) for the Sandwich Doctorate Program Abroad (PDSE) scholarship.

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• Data availability:
  The authors did not make the data from this article available in repositories prior to submission.

Edited by

• Guest associate editor:
  Manoel Vieira de Miranda Neto (https://orcid.org/0000-0002-3224-2165) Escola de Enfermagem, Universidade de São Paulo, São Paulo, SP, Brazil

Data availability

The authors did not make the data from this article available in repositories prior to submission.

Publication Dates

• Publication in this collection
  09 Feb 2026
• Date of issue
  2025

History

• Received
  25 Mar 2025
• Accepted
  8 Sept 2025