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Nursing specialities and professional practice: Current situation and future perspectives
Enferm Clin. 2019;29(6):357---363
www.elsevier.es/enfermeriaclinica
SPECIAL ARTICLE
Nursing specialities and professional practice: Current situation and future perspectives夽 Cristina Cuevas-Santos Ministerio de Ciencia, Innovación y Universidades, Madrid, Spain Received 1 October 2019; accepted 1 October 2019 Available online 11 November 2019
KEYWORDS National Health System; Patient care; Nursing specialties; Nurse competence; Investigation
PALABRAS CLAVE Sistema Nacional de Salud; Cuidados; Especialidades de Enfermería; Competencias de las enfermeras; Investigación
Abstract The establishment of nursing specialties that started in 1953 has contributed decisively to the quality of the medical care provided by the National Health System. Nowadays, a large number of nurses have an official specialist qualification achieved through different means of access established by Royal Decree on nursing specialties. Furthermore, the training programmes must continue to develop in order to complete the catalogue established under the aforementioned regulation. It should be pointed out that many specialists face difficulties in carrying out professional practice according to their education and training, due to the lack of job descriptions and identification of competences during recruitment processes and access to job positions, needed for appropriate professional performance. Therefore, it is essential to create a catalogue for specific job positions for each of the specialties to meet the expectations of professional nursing and enhance progress in quality patient care. © 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.
Especialidades de Enfermería y ejercicio profesional: situación actual y perspectivas de futuro Resumen La instauración de las especialidades de Enfermería iniciada en 1953 ha contribuido de forma decisiva en la calidad de la atención sanitaria proporcionada en el Sistema Nacional de Salud. En la actualidad, un elevado número de enfermeras poseen un título oficial de especialista obtenido a través de las distintas modalidades de acceso que establece el Real Decreto sobre especialidades de Enfermería. Por otra parte, los programas formativos tienen que seguir desarrollándose para culminar el catálogo establecido en la mencionada normativa.
DOI of original article: https://doi.org/10.1016/j.enfcli.2019.10.002 Please cite this article as: Cuevas-Santos C. Especialidades de Enfermería y ejercicio profesional: situación actual y perspectivas de futuro. Enferm Clin. 2019;29:357---364. E-mail address: [email protected] 夽
2445-1479/© 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.
358
C. Cuevas-Santos Cabe destacar que muchos especialistas tienen dificultad para llevar a cabo un ejercicio profesional acorde a su formación y capacitación, debido a la escasa descripción de puestos de trabajo e identificación de competencias en los procesos de selección y acceso a los puestos de trabajo, necesarias para un buen desempe˜ no profesional. Por ello, resulta imprescindible elaborar un catálogo de puestos de trabajo específico de cada una de las especialidades, para dar respuesta a las expectativas de las enfermeras y fortalecer el avance en la calidad de la atención de cuidados. © 2019 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction History of nurse training Before we approach the subject of nurse training, it seems appropriate to refer to the context in which these professionals practice. It is the purpose of a health system to promote health, prevent and treat disease and provide care for people. The set of elements that comprise the system must deliver services of the highest quality to ensure that people receive adequate, comfortable and safe care. In recent years, the large volume of healthcare activity, together with the increasing complexity of procedures, has led to a notable increase in the level of quality and efficiency of our health system. Patient safety is an essential element of care quality, and without it the likelihood increases that other dimensions such as efficiency, effectiveness and patient satisfaction will suffer. Similarly, the practice of health professionals is subject to continual change, due to the innovation of diagnostic means and therapeutic procedures, as well as sociodemographic changes of the population. Although the phenomenon of change is not unprecedented, our times are characterised by the speed, continuity, nature and influence of change. This means we must continuously strive to adapt to provide an adequate response to scientific and social demand. In the field of health, the responsibility and importance of care in the health organisations is evident. The evolution of nursing care has gone from opinion to scientific certainty, based on the assessment of outcomes. The International Nursing Council1 (INC) states that nurses are the main group within the health workforce, since they foster and maintain links between individuals, families, communities and the rest of the health care system, and work autonomously and collaboratively to prevent disease and disability, and to promote, improve, maintain and restore health. The relevance of nurses’ work in health systems is currently being demonstrated through the international initiative promoted by the INC and the World Health Organization (WHO), through the ‘‘Nursing Now’’2 campaign, running from 2018 to 2020 with the aim of promoting health and preventing disease worldwide, by highlighting
and improving the recognition and professional status of nurses towards achieving universal health coverage. The Director-General of the WHO, at the Assembly held in May 2019,3 stated: ‘‘WHO is proud to nominate 2020 as the Year of the Nurse and the Midwife. These two health professions are invaluable to the health of people everywhere. Without nurses and midwives, we will not achieve the Sustainable Development Goals or universal health coverage’’. In our country, the last decades have been marked by profound changes in health, derived from the transformations that have occurred in the socio-political and educational field. Similarly, in Spain, the nursing discipline has incorporated far-reaching transformations over the last 50 years. The decade of the fifties was characterised by major development of health care, embodied by the creation of large hospitals, supplied with technological equipment. This led to the need for a professional group to support all the activities derived from this innovation and health development. Three professional groups coexisted in Spain during the first half of the 20th century: practitioners, nurses and midwifes. From 1952, the study plans of these groups were combined, giving rise to a new and unique qualification, the Healthcare Technical Assistant, this being an era where the technical aspect was the dominant scientific value. The required profile was to have a high level of technical knowledge, ability and expertise to perform procedures and take on a collaborative role with the medical profession.
The beginning of nursing specialties In 1953, through issuance of a Decree,4 the education of practitioners, nurses and midwives was integrated, regulating the training of Healthcare Technical Assistants (hereinafter, ATS). It should be noted that this regulation began specialisation by assigning to the ‘‘Ministry of National Education the capacity to organise or authorise the creation of specialties that are considered suitable for ATS, as well issuing a diploma for the different specialties. The first is that of Midwife’’. The qualification of ATS enjoyed great visibility and growth. Proof of this is the development of the official
Nursing specialities and professional practice Table 1
359
Chronological implementation of the official specialties of ATS qualification.
Year
Specialty
Regulation
1957
Obstetric Care (Midwife)
1957
Physiotherapy
1961
Radiology and Electrology
1962
Chiropody
Ministry of National Education. Decree of 18 January 1957 establishing the specialisation of Midwife for female Healthcare Technical Assistants (BOE 12 February) Ministry of National Education. Decree of 26 July 1957 establishing the specialisation of ‘‘Physiotherapy’’ for Healthcare Technical Assistants (BOE 23 August Ministry of National Education. Decree 1153/1961 of 22 June, creating the specialty of ‘‘Radiology and Electrology’’ in the education of Health Technical Assistants (BOE 18 July Ministry of National Education. Decree 727/1962 of 29 March 1962, recognising and regulating the specialty of Podiatry for Healthcare Practitioners and Technical Assistants (BOE 13 April).
1964
Paediatrics and Childcare
1970
Neurology
1970
Psychiatry
1971
Clinical analyses
1975
Urology and Nephrology
Ministry of National Education. Decree 3524/1964 of 22 October, creating the specialty of ‘‘Paediatrics and Childcare’’ in the education of Healthcare Technical Assistants (BOE 11 November) Ministry of Education and Science. Decree 3192/1970, of 22 October, creating the specialty of ‘‘Neurology’’ in the education of Healthcare Technical Assistants (BOE 9 November) Ministry of Education and Science. Decree 3193/1970 of 22 October, creating the specialty of ‘‘Psychiatry’’ in the education of Health Technical Assistants (BOE 9 November) Ministry of Education and Science. Decree 203/1971, of 28 January, creating the specialty of Clinical Analysis in the education of Healthcare Technical Assistants (BOE 15 February) Decree 2233/1975, of 24 July 1975, creating the specialty of Urology and Nephrology for Healthcare Technical Assistants (BOE of 29 September).
Source: Compiled by the author.
specialties established under the chairs of Medicine, shown in Table 1. In the 1980s, the specialties of Physiotherapy and Chiropody became differentiated degrees. Along with this development, the 1970s were characterised by the incorporation of major changes at socio-political and educational levels. Article 43 of the Spanish Constitution of 1978 establishes the right to health protection and health care for all citizens. The health bases were established through the enactment of the General Health Law,5 which incorporated, among other aspects, universality of care and the concepts of health promotion and protection. The evolution of the health/disease concept, the new approaches to comprehensive care and the importance of health education confirmed the need to change nursing concepts and areas of activity. The changes in educational policy that started in the 1970s led to the integration into the university of the ATS colleges as University Colleges of Nursing.6 This integration entailed a new curricular design in which the object of the discipline was defined: professional care. From this date, nursing became an autonomous profession with its own social function and a body of specific knowledge, with the fundamental objective of helping people to take care of themselves, and to provide care to those who need it.
Royal Decree 992/19877 meant an important change in the orientation and development of the specialties of Nursing, since they were arranged in consonance with the major areas of care. Furthermore, it specified that ‘‘the title of specialist nurse issued by the Ministry of Education and Science will be obligatory to be able to expressly use the title of specialist nurse’’. The specialities established were as follows:
1. 2. 3. 4. 5. 6. 7.
Obstetric-Gynaecological Nursing (Midwives). Paediatric Nursing. Mental Health Nursing. Community Health Nursing. Special Care Nursing. Geriatric Nursing. Nursing Management and Administration.
Likewise, the National Council of Nursing Specialties and the National Commissions of Nursing Specialties were set up, both formed by nurses and responsible for preparing the training programmes for each specialty. Similarly, it was determined for the first time that training should be carried out through the residency system in ‘‘accredited teaching units to develop the corresponding training programmes, which will be supervised and
360 coordinated to this effect by the corresponding University Colleges of Nursing’’. Only two specialties of the defined catalogue have been implemented: Obstetric-Gynaecological Nursing (midwife) in 1992 and Mental Health Nursing in 1998.
Current situation and access route to specialist nurse qualification In 2005 the 1987 regulation was replaced by the current Royal Decree 450/2005,8 reiterating that the ‘‘qualification of Specialist Nurse, issued by the Ministry of Education and Science, is official and valid throughout the State and will be necessary to expressly use the title of Specialist Nurse’’. The defined specialities, with a care orientation according to the different age groups, risk groups, community care and population needs, are as follows: 1. 2. 3. 4. 5. 6. 7.
Obstetric-Gynaecological Nursing (Midwife). Mental Health Nursing. Geriatric Nursing. Occupational Health Nursing. Medical-Surgical Care Nursing. Family and Community Nursing. Paediatric Nursing.
The abovementioned Royal Decree 450/2005 establishes 4 access routes.
Standard route The model chosen since 1992 for access to specialist nurse training, like the rest of health professionals, is that of residency (EIR), with nurses holding diplomas/degrees being able to sit an annual state test that involves full time dedication, based on self-learning tutored in an accredited teaching unit, through the gradual acquisition of skills. The training programmes are devised by the National Commissions of the specialties, each made up of specialist nurses, who are also responsible for establishing the criteria for the assessment of teaching units and for the assessment of the EIR. We should highlight that all current training programmes have research content. Article 6, of Royal Decree 99/2011,9 states that ‘‘university graduates who, after obtaining a place in training in the relevant test for access to specialist health training places, have passed and obtained after at least 2 years of training in a programme the official qualification of one of the Health Science specialities, will be able to gain access to the doctorate’’, which means that having obtained the specialist qualification through the EIR system, with a two-year duration of their training programme, it is possible to gain access to a doctorate.
Second additional provision. Discontinuation of previous specialties
C. Cuevas-Santos Table 2 Direct access. Second additional provision of Royal Decree 450/2005, of 22 April, on nursing specialties. Discontinued specialty
New specialties that can be accessed
- Neurology - Urology and Nephrology - Clinical Analyses - Radiology and Electrology - Special care - Paediatrics and Childcare - Psychiatry
- Medical-Surgical Care Nursing
- Obstetric care (Midwife)
- Paediatric Nursing - Mental Health Nursing - ObstetricGynaecological Nursing (Midwife)
Source: Compiled by the author.
3. 4. 5. 6. 7. 8. 9. 10.
Clinical analyses. Radiology and Electrology. Special Care Nursing. Paediatrics and Childcare. Psychiatry. Obstetric care (Midwife). Community Health Nursing. Nursing Management and Administration.
Holders of diplomas in Nursing and ATS with specialist qualifications that have been discontinued can ask for a new specialist qualification to be issued. Under this procedure, more than 12,000 nurses have been awarded a specialist qualification. The deadline for submitting applications for a change of qualification remains open, and is carried out according to the scheme shown in Table 2.
Third transitional provision. Special regime for access to the Occupational Health Nursing qualification This specifies that graduates in Nursing and ATS who hold an ATS/DUE (university diploma in nursing) in Company or Occupational Health Nursing may directly access the Occupational Health Nursing qualification, provided they can prove that they have minimum of 4 years of professional practice in the relevant field. This process ended in May 2006, and almost 8000 nurses have obtained specialist qualification through this route.
Second transitional provision. Exceptional access to specialist qualification
The following former specialties have been discontinued: 1. Neurology. 2. Urology and Nephrology.
This provides that all graduates who can prove professional practice in the specific field of the requested specialty and pass an assessment test of competence in some of the
Nursing specialities and professional practice
361
Table 3 Exceptional access requirements to access the qualification of Nursing specialist. Second transitional provision of Royal Decree 450/2005, of 22 April, on nursing specialties. Situation
Training
(a)
(b)
Minimum of 40 accredited continuous training credits, in the field of the specialty or Post graduate university qualification, not less than 20 credits or 200 hours in the field of the specialty
(c)
Professional practice
Competence assessment test
4 years of professional practice undertaking activities specific to the specialty 2 years of professional practice in activities specific to the specialty
Passing the objective test
3 years as a teacher in University Colleges of Nursing devoted to areas of knowledge relating to the specialty. + 1 year of care activity in activities specific to the specialty
Source: Compiled by the author.
situations shown in Table 3 will be able to access a single qualification of specialist nurse, or ATS. More than 49,000 nurses currently hold an official specialist degree obtained through the different established access routes, i.e., through automatic access from the former discontinued specialties, special access to the Occupational Health Nursing specialty, through the exceptional route and through the residency system (EIR). Exceptional route The deadline for submitting applications and the process for obtaining the qualification of specialist nurse in Mental Health Nursing, Occupational Health Nursing, Geriatric Nursing and Paediatric Nursing have now passed, and more than 19,000 nurses have used this route to gain specialist qualification. Applications for exceptional access to the specialty of Family and Community Nursing are currently being considered, as a preliminary phase to the call for objective proof for this specialty. Residency system (EIR) From 1993 to the present date, the Ministry of Health, Consumption and Social Welfare has offered the EIR positions described in Table 4. We should highlight that the training programme for the specialty of Medical-Surgical Care Nursing has not yet been approved, and therefore its specific scope cannot be outlined. The National Commission for this speciality continues to work on formulating the training programme, which must be approved and published in the Official State Gazette prior to announcing that training places in this speciality
are offered for the first time. It is possible that the title of this specialty has made it difficult to outline the profile.
Conclusions and future prospects Social changes, new demands and emerging situations in the field of health, and the increasing complexity of responding to different care contexts, require the incorporation of care professionals capable of meeting specific health needs, able to develop new competences through professional advancement associated with these areas of specific care to which each specialty refers. These aspects justify the consolidation of nursing specialties, without leaving out the highly prestigious and recognised generalist profiles of Spanish nurses that are uncontested within our health system. As can be observed, the development of nursing specialties and the high number of specialists provide clear impetus in the evolution of the nursing discipline in our country. It only remains for us to highlight the need for a detailed description of jobs specific to specialist nurses, as a phase prior to their incorporation into healthcare activity since, when a professional is adjusted to his or her job, they must adapt to it, i.e., there should be agreement between their professional attributes and the demands and needs of the job. If, on the other hand, there is a mismatch between the professional characteristics and the requirements of the job, this is because there is a gap between the skills required for the job and those developed by the professional, which must be identified.10 For all these reasons, it is essential to draw up a catalogue of jobs, identifying the skills of specialist nurses, thus guiding selection processes that enable access
362
Table 4
Chronological development of the offer of specialist Nursing training places 1993---2019. Offer of specialist Nursing training places 1993---2019
Year
BOE publication
Midwife Places offered
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order
01/06/1992. BOE 23/10/1993 21/07/1994. BOE 27/07 2/08/1995. BOE 04/08 26/07/1996. BOE 30/07 24/07/1997. BOE 31/07 30/07/1998. BOE 04/08 30/07/1999. BOE 03/08 01/08/2000. BOE 03/08 07/11/2001. BOE 09/11 29/10/2002. BOE 02/11 15/10/2003. BOE 17/10 27/09/2004. BOE 01/10 16/09/2005. BOE 22/09 14/09/2006. BOE 22/09 SCO/2706/2007. BOE 19/09 SCO/2643/2008. BOE 19/09 SAS/2511/2009. BOE 22/09 SAS 2447/2010. BOE 22/09 SPI/2548/2011. BOE 26/09 SSI/1997/2012. BOE 22/12 SSI/1694/2013. BOE 23/09 SSI/1674/2014. BOE 17/09 SSI/1892/2015. BOE 18/09 SSI/1461/2016. BOE 13/09 SSI/876/2017. BOE 15/09 SCB/947/2018. BOE 14/09 SCB/925/2019. BOE 09/09
Source: Compiled by the author.
Occupational Health Places offered
Geriatrics Places offered
Family and Community Places offered
Paediatrics Places offered
174 86 161 101 183 97 197 117 204 229 297 314 320 357 355 418 445 461 458 423 395 374 366 368 375 379 401
21 55 71 82 84 101 107 111 124 133 149 154 178 198 188 182 181 183 183 193 203 245
12 13 15 22 21 19 14 17 18 18 62
12 14 11 13 11 15 19 21 20 46
132 219 214 244 267 278 293 316 339 521
52 98 105 106 107 112 114 128 133 188
8055
3126
231
182
2823
1143
C. Cuevas-Santos
Total places offered: 15,560
Mental Health Places offered
Nursing specialities and professional practice to the most suitable professionals to meet the expectations of the profession and improve the quality of the National Health System.
Funding No funding was received.
Conflict of interests The author has no conflict of interests to declare.
References 1. Consejo Internacional de Enfermeras. Servir a la comunidad y garantizar la calidad: Las enfermeras al frente de la atención primaria de salud [Internet]. Ginebra, Suiza; 2008. Available at: https://www.consejogeneralenfermeria.org/internacional/ cie/send/25-cie/342-02-4-da-internacional-de-la-enfermera2008-servir-a-la-comunidad-y-garantizar-la-calidad. [Accessed 13 September 2019]. 2. Organización Mundial de la Salud: Atención de enfermería y partería [Internet]. Ginebra, Suiza; 2008. Available at: https://www.who.int/es/news-room/fact-sheets/detail/ nursing-and-midwifery. [Accessed 13 September 2019].
363 3. Organización Mundial de la Salud: Congreso del Consejo Internacional de Enfermeras de 2019: Discurso del Dr. Tedros Adhanom Ghebreyesus en Singapur [Internet]; 2019. Available at: https:// www.who.int/es/dg/speeches/detail/international-council-ofnurses-2019-congress. [Accessed 13 September 2019]. 4. Decreto de 4 de diciembre de 1953, por el que se unifican los estudios de las profesiones de Auxiliares Sanitarios. Boletín Oficial del Estado, número 363, de 29 de diciembre de 1953. 5. Ley 14/1986, de 25 de abril, General de Sanidad. Boletín Oficial del Estado, número 102, de 29 de abril de 1986. 6. Real Decreto 2128/1977, de 23 de julio, sobre integración en la Universidad de las Escuelas de Ayudantes Técnicos Sanitarios como Escuelas Universitarias de Enfermería. Boletín Oficial del Estado, número 200, de 22 de agosto de 1977. 7. Real Decreto 992/1987, de 3 de julio, por el que se regula la obtención del título de Enfermero especialista. Boletín Oficial del Estado, número 183, de 1 de agosto de 1987. 8. Real Decreto 450/2005, de 22 de abril, sobre especialidades de Enfermería. Boletín Oficial del Estado, número 108, de 6 de mayo de 2005. 9. Real Decreto 99/2011, de 28 de enero, por el que se regulan las ense˜ nanzas oficiales de doctorado. Boletín Oficial del Estado, número 35, de 10 de febrero de 2011. 10. Cuevas C, Martínez I, Baltanás FJ. La gestión por competencias en enfermería: hazlo diferente. 1.a ed Difusión Avances de Enfermería; 2006.
www.elsevier.es/enfermeriaclinica
SPECIAL ARTICLE
Nursing specialities and professional practice: Current situation and future perspectives夽 Cristina Cuevas-Santos Ministerio de Ciencia, Innovación y Universidades, Madrid, Spain Received 1 October 2019; accepted 1 October 2019 Available online 11 November 2019
KEYWORDS National Health System; Patient care; Nursing specialties; Nurse competence; Investigation
PALABRAS CLAVE Sistema Nacional de Salud; Cuidados; Especialidades de Enfermería; Competencias de las enfermeras; Investigación
Abstract The establishment of nursing specialties that started in 1953 has contributed decisively to the quality of the medical care provided by the National Health System. Nowadays, a large number of nurses have an official specialist qualification achieved through different means of access established by Royal Decree on nursing specialties. Furthermore, the training programmes must continue to develop in order to complete the catalogue established under the aforementioned regulation. It should be pointed out that many specialists face difficulties in carrying out professional practice according to their education and training, due to the lack of job descriptions and identification of competences during recruitment processes and access to job positions, needed for appropriate professional performance. Therefore, it is essential to create a catalogue for specific job positions for each of the specialties to meet the expectations of professional nursing and enhance progress in quality patient care. © 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.
Especialidades de Enfermería y ejercicio profesional: situación actual y perspectivas de futuro Resumen La instauración de las especialidades de Enfermería iniciada en 1953 ha contribuido de forma decisiva en la calidad de la atención sanitaria proporcionada en el Sistema Nacional de Salud. En la actualidad, un elevado número de enfermeras poseen un título oficial de especialista obtenido a través de las distintas modalidades de acceso que establece el Real Decreto sobre especialidades de Enfermería. Por otra parte, los programas formativos tienen que seguir desarrollándose para culminar el catálogo establecido en la mencionada normativa.
DOI of original article: https://doi.org/10.1016/j.enfcli.2019.10.002 Please cite this article as: Cuevas-Santos C. Especialidades de Enfermería y ejercicio profesional: situación actual y perspectivas de futuro. Enferm Clin. 2019;29:357---364. E-mail address: [email protected] 夽
2445-1479/© 2019 Elsevier Espa˜ na, S.L.U. All rights reserved.
358
C. Cuevas-Santos Cabe destacar que muchos especialistas tienen dificultad para llevar a cabo un ejercicio profesional acorde a su formación y capacitación, debido a la escasa descripción de puestos de trabajo e identificación de competencias en los procesos de selección y acceso a los puestos de trabajo, necesarias para un buen desempe˜ no profesional. Por ello, resulta imprescindible elaborar un catálogo de puestos de trabajo específico de cada una de las especialidades, para dar respuesta a las expectativas de las enfermeras y fortalecer el avance en la calidad de la atención de cuidados. © 2019 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction History of nurse training Before we approach the subject of nurse training, it seems appropriate to refer to the context in which these professionals practice. It is the purpose of a health system to promote health, prevent and treat disease and provide care for people. The set of elements that comprise the system must deliver services of the highest quality to ensure that people receive adequate, comfortable and safe care. In recent years, the large volume of healthcare activity, together with the increasing complexity of procedures, has led to a notable increase in the level of quality and efficiency of our health system. Patient safety is an essential element of care quality, and without it the likelihood increases that other dimensions such as efficiency, effectiveness and patient satisfaction will suffer. Similarly, the practice of health professionals is subject to continual change, due to the innovation of diagnostic means and therapeutic procedures, as well as sociodemographic changes of the population. Although the phenomenon of change is not unprecedented, our times are characterised by the speed, continuity, nature and influence of change. This means we must continuously strive to adapt to provide an adequate response to scientific and social demand. In the field of health, the responsibility and importance of care in the health organisations is evident. The evolution of nursing care has gone from opinion to scientific certainty, based on the assessment of outcomes. The International Nursing Council1 (INC) states that nurses are the main group within the health workforce, since they foster and maintain links between individuals, families, communities and the rest of the health care system, and work autonomously and collaboratively to prevent disease and disability, and to promote, improve, maintain and restore health. The relevance of nurses’ work in health systems is currently being demonstrated through the international initiative promoted by the INC and the World Health Organization (WHO), through the ‘‘Nursing Now’’2 campaign, running from 2018 to 2020 with the aim of promoting health and preventing disease worldwide, by highlighting
and improving the recognition and professional status of nurses towards achieving universal health coverage. The Director-General of the WHO, at the Assembly held in May 2019,3 stated: ‘‘WHO is proud to nominate 2020 as the Year of the Nurse and the Midwife. These two health professions are invaluable to the health of people everywhere. Without nurses and midwives, we will not achieve the Sustainable Development Goals or universal health coverage’’. In our country, the last decades have been marked by profound changes in health, derived from the transformations that have occurred in the socio-political and educational field. Similarly, in Spain, the nursing discipline has incorporated far-reaching transformations over the last 50 years. The decade of the fifties was characterised by major development of health care, embodied by the creation of large hospitals, supplied with technological equipment. This led to the need for a professional group to support all the activities derived from this innovation and health development. Three professional groups coexisted in Spain during the first half of the 20th century: practitioners, nurses and midwifes. From 1952, the study plans of these groups were combined, giving rise to a new and unique qualification, the Healthcare Technical Assistant, this being an era where the technical aspect was the dominant scientific value. The required profile was to have a high level of technical knowledge, ability and expertise to perform procedures and take on a collaborative role with the medical profession.
The beginning of nursing specialties In 1953, through issuance of a Decree,4 the education of practitioners, nurses and midwives was integrated, regulating the training of Healthcare Technical Assistants (hereinafter, ATS). It should be noted that this regulation began specialisation by assigning to the ‘‘Ministry of National Education the capacity to organise or authorise the creation of specialties that are considered suitable for ATS, as well issuing a diploma for the different specialties. The first is that of Midwife’’. The qualification of ATS enjoyed great visibility and growth. Proof of this is the development of the official
Nursing specialities and professional practice Table 1
359
Chronological implementation of the official specialties of ATS qualification.
Year
Specialty
Regulation
1957
Obstetric Care (Midwife)
1957
Physiotherapy
1961
Radiology and Electrology
1962
Chiropody
Ministry of National Education. Decree of 18 January 1957 establishing the specialisation of Midwife for female Healthcare Technical Assistants (BOE 12 February) Ministry of National Education. Decree of 26 July 1957 establishing the specialisation of ‘‘Physiotherapy’’ for Healthcare Technical Assistants (BOE 23 August Ministry of National Education. Decree 1153/1961 of 22 June, creating the specialty of ‘‘Radiology and Electrology’’ in the education of Health Technical Assistants (BOE 18 July Ministry of National Education. Decree 727/1962 of 29 March 1962, recognising and regulating the specialty of Podiatry for Healthcare Practitioners and Technical Assistants (BOE 13 April).
1964
Paediatrics and Childcare
1970
Neurology
1970
Psychiatry
1971
Clinical analyses
1975
Urology and Nephrology
Ministry of National Education. Decree 3524/1964 of 22 October, creating the specialty of ‘‘Paediatrics and Childcare’’ in the education of Healthcare Technical Assistants (BOE 11 November) Ministry of Education and Science. Decree 3192/1970, of 22 October, creating the specialty of ‘‘Neurology’’ in the education of Healthcare Technical Assistants (BOE 9 November) Ministry of Education and Science. Decree 3193/1970 of 22 October, creating the specialty of ‘‘Psychiatry’’ in the education of Health Technical Assistants (BOE 9 November) Ministry of Education and Science. Decree 203/1971, of 28 January, creating the specialty of Clinical Analysis in the education of Healthcare Technical Assistants (BOE 15 February) Decree 2233/1975, of 24 July 1975, creating the specialty of Urology and Nephrology for Healthcare Technical Assistants (BOE of 29 September).
Source: Compiled by the author.
specialties established under the chairs of Medicine, shown in Table 1. In the 1980s, the specialties of Physiotherapy and Chiropody became differentiated degrees. Along with this development, the 1970s were characterised by the incorporation of major changes at socio-political and educational levels. Article 43 of the Spanish Constitution of 1978 establishes the right to health protection and health care for all citizens. The health bases were established through the enactment of the General Health Law,5 which incorporated, among other aspects, universality of care and the concepts of health promotion and protection. The evolution of the health/disease concept, the new approaches to comprehensive care and the importance of health education confirmed the need to change nursing concepts and areas of activity. The changes in educational policy that started in the 1970s led to the integration into the university of the ATS colleges as University Colleges of Nursing.6 This integration entailed a new curricular design in which the object of the discipline was defined: professional care. From this date, nursing became an autonomous profession with its own social function and a body of specific knowledge, with the fundamental objective of helping people to take care of themselves, and to provide care to those who need it.
Royal Decree 992/19877 meant an important change in the orientation and development of the specialties of Nursing, since they were arranged in consonance with the major areas of care. Furthermore, it specified that ‘‘the title of specialist nurse issued by the Ministry of Education and Science will be obligatory to be able to expressly use the title of specialist nurse’’. The specialities established were as follows:
1. 2. 3. 4. 5. 6. 7.
Obstetric-Gynaecological Nursing (Midwives). Paediatric Nursing. Mental Health Nursing. Community Health Nursing. Special Care Nursing. Geriatric Nursing. Nursing Management and Administration.
Likewise, the National Council of Nursing Specialties and the National Commissions of Nursing Specialties were set up, both formed by nurses and responsible for preparing the training programmes for each specialty. Similarly, it was determined for the first time that training should be carried out through the residency system in ‘‘accredited teaching units to develop the corresponding training programmes, which will be supervised and
360 coordinated to this effect by the corresponding University Colleges of Nursing’’. Only two specialties of the defined catalogue have been implemented: Obstetric-Gynaecological Nursing (midwife) in 1992 and Mental Health Nursing in 1998.
Current situation and access route to specialist nurse qualification In 2005 the 1987 regulation was replaced by the current Royal Decree 450/2005,8 reiterating that the ‘‘qualification of Specialist Nurse, issued by the Ministry of Education and Science, is official and valid throughout the State and will be necessary to expressly use the title of Specialist Nurse’’. The defined specialities, with a care orientation according to the different age groups, risk groups, community care and population needs, are as follows: 1. 2. 3. 4. 5. 6. 7.
Obstetric-Gynaecological Nursing (Midwife). Mental Health Nursing. Geriatric Nursing. Occupational Health Nursing. Medical-Surgical Care Nursing. Family and Community Nursing. Paediatric Nursing.
The abovementioned Royal Decree 450/2005 establishes 4 access routes.
Standard route The model chosen since 1992 for access to specialist nurse training, like the rest of health professionals, is that of residency (EIR), with nurses holding diplomas/degrees being able to sit an annual state test that involves full time dedication, based on self-learning tutored in an accredited teaching unit, through the gradual acquisition of skills. The training programmes are devised by the National Commissions of the specialties, each made up of specialist nurses, who are also responsible for establishing the criteria for the assessment of teaching units and for the assessment of the EIR. We should highlight that all current training programmes have research content. Article 6, of Royal Decree 99/2011,9 states that ‘‘university graduates who, after obtaining a place in training in the relevant test for access to specialist health training places, have passed and obtained after at least 2 years of training in a programme the official qualification of one of the Health Science specialities, will be able to gain access to the doctorate’’, which means that having obtained the specialist qualification through the EIR system, with a two-year duration of their training programme, it is possible to gain access to a doctorate.
Second additional provision. Discontinuation of previous specialties
C. Cuevas-Santos Table 2 Direct access. Second additional provision of Royal Decree 450/2005, of 22 April, on nursing specialties. Discontinued specialty
New specialties that can be accessed
- Neurology - Urology and Nephrology - Clinical Analyses - Radiology and Electrology - Special care - Paediatrics and Childcare - Psychiatry
- Medical-Surgical Care Nursing
- Obstetric care (Midwife)
- Paediatric Nursing - Mental Health Nursing - ObstetricGynaecological Nursing (Midwife)
Source: Compiled by the author.
3. 4. 5. 6. 7. 8. 9. 10.
Clinical analyses. Radiology and Electrology. Special Care Nursing. Paediatrics and Childcare. Psychiatry. Obstetric care (Midwife). Community Health Nursing. Nursing Management and Administration.
Holders of diplomas in Nursing and ATS with specialist qualifications that have been discontinued can ask for a new specialist qualification to be issued. Under this procedure, more than 12,000 nurses have been awarded a specialist qualification. The deadline for submitting applications for a change of qualification remains open, and is carried out according to the scheme shown in Table 2.
Third transitional provision. Special regime for access to the Occupational Health Nursing qualification This specifies that graduates in Nursing and ATS who hold an ATS/DUE (university diploma in nursing) in Company or Occupational Health Nursing may directly access the Occupational Health Nursing qualification, provided they can prove that they have minimum of 4 years of professional practice in the relevant field. This process ended in May 2006, and almost 8000 nurses have obtained specialist qualification through this route.
Second transitional provision. Exceptional access to specialist qualification
The following former specialties have been discontinued: 1. Neurology. 2. Urology and Nephrology.
This provides that all graduates who can prove professional practice in the specific field of the requested specialty and pass an assessment test of competence in some of the
Nursing specialities and professional practice
361
Table 3 Exceptional access requirements to access the qualification of Nursing specialist. Second transitional provision of Royal Decree 450/2005, of 22 April, on nursing specialties. Situation
Training
(a)
(b)
Minimum of 40 accredited continuous training credits, in the field of the specialty or Post graduate university qualification, not less than 20 credits or 200 hours in the field of the specialty
(c)
Professional practice
Competence assessment test
4 years of professional practice undertaking activities specific to the specialty 2 years of professional practice in activities specific to the specialty
Passing the objective test
3 years as a teacher in University Colleges of Nursing devoted to areas of knowledge relating to the specialty. + 1 year of care activity in activities specific to the specialty
Source: Compiled by the author.
situations shown in Table 3 will be able to access a single qualification of specialist nurse, or ATS. More than 49,000 nurses currently hold an official specialist degree obtained through the different established access routes, i.e., through automatic access from the former discontinued specialties, special access to the Occupational Health Nursing specialty, through the exceptional route and through the residency system (EIR). Exceptional route The deadline for submitting applications and the process for obtaining the qualification of specialist nurse in Mental Health Nursing, Occupational Health Nursing, Geriatric Nursing and Paediatric Nursing have now passed, and more than 19,000 nurses have used this route to gain specialist qualification. Applications for exceptional access to the specialty of Family and Community Nursing are currently being considered, as a preliminary phase to the call for objective proof for this specialty. Residency system (EIR) From 1993 to the present date, the Ministry of Health, Consumption and Social Welfare has offered the EIR positions described in Table 4. We should highlight that the training programme for the specialty of Medical-Surgical Care Nursing has not yet been approved, and therefore its specific scope cannot be outlined. The National Commission for this speciality continues to work on formulating the training programme, which must be approved and published in the Official State Gazette prior to announcing that training places in this speciality
are offered for the first time. It is possible that the title of this specialty has made it difficult to outline the profile.
Conclusions and future prospects Social changes, new demands and emerging situations in the field of health, and the increasing complexity of responding to different care contexts, require the incorporation of care professionals capable of meeting specific health needs, able to develop new competences through professional advancement associated with these areas of specific care to which each specialty refers. These aspects justify the consolidation of nursing specialties, without leaving out the highly prestigious and recognised generalist profiles of Spanish nurses that are uncontested within our health system. As can be observed, the development of nursing specialties and the high number of specialists provide clear impetus in the evolution of the nursing discipline in our country. It only remains for us to highlight the need for a detailed description of jobs specific to specialist nurses, as a phase prior to their incorporation into healthcare activity since, when a professional is adjusted to his or her job, they must adapt to it, i.e., there should be agreement between their professional attributes and the demands and needs of the job. If, on the other hand, there is a mismatch between the professional characteristics and the requirements of the job, this is because there is a gap between the skills required for the job and those developed by the professional, which must be identified.10 For all these reasons, it is essential to draw up a catalogue of jobs, identifying the skills of specialist nurses, thus guiding selection processes that enable access
362
Table 4
Chronological development of the offer of specialist Nursing training places 1993---2019. Offer of specialist Nursing training places 1993---2019
Year
BOE publication
Midwife Places offered
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order Order
01/06/1992. BOE 23/10/1993 21/07/1994. BOE 27/07 2/08/1995. BOE 04/08 26/07/1996. BOE 30/07 24/07/1997. BOE 31/07 30/07/1998. BOE 04/08 30/07/1999. BOE 03/08 01/08/2000. BOE 03/08 07/11/2001. BOE 09/11 29/10/2002. BOE 02/11 15/10/2003. BOE 17/10 27/09/2004. BOE 01/10 16/09/2005. BOE 22/09 14/09/2006. BOE 22/09 SCO/2706/2007. BOE 19/09 SCO/2643/2008. BOE 19/09 SAS/2511/2009. BOE 22/09 SAS 2447/2010. BOE 22/09 SPI/2548/2011. BOE 26/09 SSI/1997/2012. BOE 22/12 SSI/1694/2013. BOE 23/09 SSI/1674/2014. BOE 17/09 SSI/1892/2015. BOE 18/09 SSI/1461/2016. BOE 13/09 SSI/876/2017. BOE 15/09 SCB/947/2018. BOE 14/09 SCB/925/2019. BOE 09/09
Source: Compiled by the author.
Occupational Health Places offered
Geriatrics Places offered
Family and Community Places offered
Paediatrics Places offered
174 86 161 101 183 97 197 117 204 229 297 314 320 357 355 418 445 461 458 423 395 374 366 368 375 379 401
21 55 71 82 84 101 107 111 124 133 149 154 178 198 188 182 181 183 183 193 203 245
12 13 15 22 21 19 14 17 18 18 62
12 14 11 13 11 15 19 21 20 46
132 219 214 244 267 278 293 316 339 521
52 98 105 106 107 112 114 128 133 188
8055
3126
231
182
2823
1143
C. Cuevas-Santos
Total places offered: 15,560
Mental Health Places offered
Nursing specialities and professional practice to the most suitable professionals to meet the expectations of the profession and improve the quality of the National Health System.
Funding No funding was received.
Conflict of interests The author has no conflict of interests to declare.
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363 3. Organización Mundial de la Salud: Congreso del Consejo Internacional de Enfermeras de 2019: Discurso del Dr. Tedros Adhanom Ghebreyesus en Singapur [Internet]; 2019. Available at: https:// www.who.int/es/dg/speeches/detail/international-council-ofnurses-2019-congress. [Accessed 13 September 2019]. 4. Decreto de 4 de diciembre de 1953, por el que se unifican los estudios de las profesiones de Auxiliares Sanitarios. Boletín Oficial del Estado, número 363, de 29 de diciembre de 1953. 5. Ley 14/1986, de 25 de abril, General de Sanidad. Boletín Oficial del Estado, número 102, de 29 de abril de 1986. 6. Real Decreto 2128/1977, de 23 de julio, sobre integración en la Universidad de las Escuelas de Ayudantes Técnicos Sanitarios como Escuelas Universitarias de Enfermería. Boletín Oficial del Estado, número 200, de 22 de agosto de 1977. 7. Real Decreto 992/1987, de 3 de julio, por el que se regula la obtención del título de Enfermero especialista. Boletín Oficial del Estado, número 183, de 1 de agosto de 1987. 8. Real Decreto 450/2005, de 22 de abril, sobre especialidades de Enfermería. Boletín Oficial del Estado, número 108, de 6 de mayo de 2005. 9. Real Decreto 99/2011, de 28 de enero, por el que se regulan las ense˜ nanzas oficiales de doctorado. Boletín Oficial del Estado, número 35, de 10 de febrero de 2011. 10. Cuevas C, Martínez I, Baltanás FJ. La gestión por competencias en enfermería: hazlo diferente. 1.a ed Difusión Avances de Enfermería; 2006.