My Scope of Practice: Improving Care One Translation at a Time

Compassion is the desire that moves the individual self to widen the scope of its self-concern to embrace the whole of the universal self. — Arnold Toynbee

     Maria Helena Larcher Caliri, RN, BSN, PhD, São Paulo, Brazil has been an Associate Professor at Ribeirao Preto College of Nursing, University of São Paulo since 1996. A member of Sigma Theta Tau International Nursing Honor Society and former president of the society’s Brazilian Chapter, Rho Upsilon, Maria also has been an active member of the Brazilian Nursing Association since 1976. Before completing her PhD at the University of São Paulo, she spent a year at the University of Illinois (Urbana-Champaign, IL) as both supervisor and head nurse of various small hospitals. When she started her teaching career at the University of Sao Paulo, Maria initiated research related to pressure ulcer and wound care in addition to coordinating a research group of undergrad, masters, and doctoral students.

     Maria’s experiences allow her to compare healthcare in Brazil to other countries. Sectors of healthcare in Brazil are vastly different than those in the US. “Most people in Brazil depend on the public segment formed by institutions linked to federal, state, and local governments,” Maria explains. “These range from primary healthcare to secondary health centers and large tertiary hospitals that are arranged hierarchically according to a level of complexity and type. There are no nursing homes like in the US. We have some small long-term health institutions for private patients, many regulated by religious institutions. Equipment and material for adequate pressure ulcer prevention and treatment are scarce within most of these institutions; therefore, pressure ulcer incidence is high. Families of these patients are usually the caregivers following discharge. Although pressure ulcer incidence is sometimes lower in Brazil’s autonomous private healthcare segment where individuals or corporate health plans pay for care, statistics are not well maintained in either system.”

     Maria says Brazilian healthcare providers have access to many products from international companies. “We use hydrocolloids, hydrogel, calcium alginates, dressings with silver, and also some products manufactured here as sulfadiazina (Silvadene),” she says. “Negative pressure therapy is used, but not as frequently as in the US. Special beds and mattresses are not common. Foam egg-crate and air overlays are used infrequently. Special beds and mattresses are not common, even for patients with Stage III and Stage IV ulcers, because only private hospitals and wealthy patients can afford the cost of adequate equipment. Prevention is still not the focus of care in most institutions and many people do not have adequate knowledge of evidence-based care. We acquire most of our wound care information from articles and from company presentations during conferences and vendor demonstrations. Convincing hospital administrators of the importance of some products is not easy, seeing that regulations in Brazil are still not as strong as they are in US, Canada, or the UK.”

     For example, Maria was first introduced to the Braden Scale in 1991 during her internship in America. Observing nursing practice was not one of her PhD requirements, nor was it related to her studies at the time. But in late 1995, while preparing for her job at University of São Paulo, Maria decided to research pressure ulcer risk factors and incidence at the University Hospital. While preparing her literature review, she learned about the National Pressure Ulcer Advisory Panel (NPUAP) and Agency for Healthcare Research and Quality (AHRQ) guidelines. When those references were not available in Brazil (the Internet was in its infancy), Maria wrote to the editor of Decubitus and to the AHCPR (the precursor of the AHRQ) to request copies of the articles and the guidelines. Once she received the information, she immediately began studying and researching.

      “As part of a research proposal, I wrote Dr. Braden and asked permission to translate the scale into Portuguese,” Maria says. “Another nurse who was pursuing her Masters degree did the cross-cultural and semantic validation for Brazilian speakers. We distributed the translation in Brazil through a home page on the School of Nursing website in 1998. Since that time I have partnered with the Brazilian WOCN Association to help spread knowledge about wound care and prevention.”

     Maria subscribes to journals, attends conferences, and stays in touch with colleagues in the US to stay abreast of the evolving field of wound care. She met Dr. Barbara Pieper of Wayne State University (Detroit, MI) through her research presentation during the International Council of Nursing conference in Vancouver in 1997. “She was not there when I came to see the exhibition, but I took notes of her data and continued looking for her publications in nursing journals,” Maria says. “Finally, in 1999 I wrote to her at Wayne State and asked if she would be interested in coming to Brazil to help me decipher AHCPR guidelines and research methodology for nurses and nursing graduate students. She graciously accepted; coincidentally, around the same time, Wayne State had a grant to bring international professionals to the US. Dr. Pieper invited me in 2000 and I gladly accepted.”

     While in the US, Maria and her colleagues started developing the modules for distance learning related to pressure, venous, and diabetic foot ulcers. “We wrote it in English and later did the Portuguese translation,” says Maria. “This information has been a part of our school’s website since 2001 and is used by Brazilians as well as other Portuguese speakers throughout Portugal and Africa. This year a graduate student is updating the information; it also includes review articles and publications authored by Brazilian nurses.”

     Meanwhile, Maria and Dr. Pieper’s professional relationship continues to grow along with their work endeavors. “Barbara has been a wonderful mentor who encourages and inspires me,” says Maria. “Last year she convinced me that the NPUAP’s biennial conference would be a great opportunity for me to present some of the studies I have conducted in Brazil with the graduate students. I received a grant from my university and was able to attend. I also learned about the NPUAP-EPUAP International Guidelines for pressure ulcer prevention and treatment. It was a unique experience, seeing the multidisciplinary and international collaborative work of so many professionals. I participated as a stakeholder, reviewing the draft recommendations on the NPUAP and EPUAP websites.”

     Barbara and Maria would like to do more together, but international collaborative research is not easy to accomplish and depends greatly on funding and free time. Maria encourages her Brazilian colleagues to foster their own partnerships to fulfill the need for additional research. The importance of collaborative research was underscored when Maria spent a year as a visiting scholar at the University of Michigan (Ann Arbor), where she discussed research and teaching practices and spent some time in many services of the UM Health System, including the rehabilitation unit where she learned about the UM Model Spinal Cord Injury (SCI) Care System and observed the work of the interdisciplinary team related to discharge planning for patients. “The most significant aspect of this experience was recognizing that when you have resources and legislation to support the work of professionals, you can do a lot to improve what we do,” Maria says.

     Maria envisions more collaborative work in her field as more Brazilians gain computer and Internet access and knowledge. Maria is aware that wound care professionals are organizing themselves in nursing specialty societies and trying to make contributions to national public health policies in order to have regional and national scientific meetings that bring both national and international experts from clinical and academic backgrounds together.

     Nursing in Brazil is practiced by 1) registered nurses who graduate from the universities and have a total of 15 years of education (20%), 2) nursing technicians who have 11 years of education, including high school nursing courses (15%), and 3) nursing auxiliaries who have 8 years of education and 1 year of nursing training (65%). Universities prepare baccalaureate nurses primarily to function administratively over the other nursing personnel and to coordinate patient care. Nursing specialties, as WOCN programs usually require 2 to 3 months of classes, hands on practice, and a monographic work at the end. Currently, Brazil has eight WOCN programs in different states, mostly in the southeast region. Not quite 500 Brazilian WOCN nurses serve a population of 180 million. Maria does not have a WOCN certification; she learned her wound care nursing skills by studying, observing, and taking care of patients with her students and by discussing cases with colleagues from interdisciplinary teams in Brazil and various other countries.

     Maria is proud of how much nurses can do to help people improve their knowledge about health and self care. “Despite the limited amount of staff, resources, and low salaries, the work we do as a health team is impressive,” she says. “We have to continue working to improve nursing and a nurse’s status and recognition, not only here in Brazil, but on a universal level.” She recognizes that sufficient care and prevention go hand-in-hand for pressure ulcer prevention. “What fascinates me is when I see a patient at high risk for a pressure ulcer who does not develop the wound because of the good care and education that nurses or other professionals provide,” she says.

     Her students sometimes ask Maria, “You really like to see a wound don’t you?” She responds, “I like to see a prevention method exercised or at least that patients improve while in our hospital because they know what they need to do for healing or prevention.” Whether Maria is conducting research, assisting students, working with pressure ulcers internationally, or translating the guidelines into Portuguese, every component contributes to her scope of practice.

This article was not subject to the Ostomy Wound Management peer-review process.