Hrev_master Healthcare in Low-resource Settings 2024; volume 12:12376 Multidisciplinary nursing practice in a low-resource setting in Southeast Brazil Bruno Henrique Souza Izidório,1 Kátia Eliane Santos Avelar,1 Flávia dos Santos Lugão de Souza,2 Patricia Maria Dusek,1 Agnaldo José Lopes,1,3 1Local Development Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro; 2Faculty of the Future, Manhuaçu, Brazil; 3Rehabilitation Sciences Post-Graduation Program, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil Abstract The various specializations available to nurses represent an investment geared toward providing more qualified patient care. However, little is known about the attitudes of specialized nurses toward multidisciplinarity. The purpose of this study was to inves- tigate nurses’ perceptions of multidisciplinarity in the field of spe- cialist nurses, as well as to determine how specialization is associ- ated with improved patient care and nurses’ age in a low-resource setting in Southeast Brazil. This cross-sectional study included 70 nurses aged ≥18 years with at least one nursing specialty working at the Regional Health Superintendence of Manhuaçu, Minas Gerais, Brazil. The study participants responded to questions about specialization and its importance in the field of health care. The majority of nurse specialists (84.3%) were between the ages of 20 and 40, and 31.4 percent worked in family health. Eighty percent of nurse specialists agreed that nursing specialization was impor- tant. More than 75% agreed that specialization promotes higher quality care and that multidisciplinarity is critical for improving patient care. Seventy percent of participants distrusted online health information. There is a relationship between the importance of having a specialty and better patient care (τb=0.293, p=0.002), and between being a specialist nurse and age (τb=-0.272, p=0.004). Nurses have embraced the concept of multidisciplinarity as a way to improve healthcare. However, they were concerned about the qualifications for nursing specialties. Introduction Based on tools and principles, knowledge is understood as the act of knowing, having an idea, or getting a sense of something through information to increase the effectiveness and value of ser- vices.1 In addition, knowledge is the driving force of today’s world, being a critical point for creating value for institutions, including those in the healthcare field.2 Continuing education in nursing offers nursing professionals the opportunity to become trained and licensed in a variety of specialties, where each special- ty increases their abilities to provide improved patient care.3 The improvement of prior knowledge and the development of new knowledge are essential for professional training in a low-resource setting and, consequently, contribute to the continuous improve- ment of service quality.4 This training is aimed at promoting and maintaining health, preventing diseases, and encouraging adapt- ability through physical, mental, and social aspects of life.3 The various post-degree specialization programs available for nurses are an investment in their professional identities and better patient care.5,6 In 2020, the World Health Organization (WHO) highlight- Correspondence: Agnaldo José Lopes, Local Development Post- Graduation Program, Augusto Motta University Center - Rua Dona Isabel, 94, Bonsucesso, 21032-060, Rio de Janeiro, Brazil. Tel.: +552125762020 E-mail: agnaldolopes.uerj@gmail.com Key words: motivation, nurse-patient relations, nursing, professional training, specialization Contributions: BHSI, conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing – original draft, writing – review & editing; KESA, PMD, FSLS, formal analysis, writing – original draft, writing – review and editing; AJL conceptualization, funding acquisition, investi- gation, supervision, visualization, writing – original draft, writing – review and editing. Funding: the Conselho Nacional de Desenvolvimento Científico e Tecnólogico [CNPq; Grant numbers #301967/2022-9 and #401633/2023-3], Brazil, the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro [FAPERJ; Grant number #E- 26/200.929/2022], Brazil, and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior [CAPES, FinanceCode 001, 88881.708719/2022-01, and 88887.708718/2022-00], Brazil. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the study was approved by the Research Ethics Committee of the Centro Universitário Augusto Motta under the number CAAE-50714121.2.0000.5235, and all participants signed the consent form. The study followed the recommendations for research in humans as per the Declaration of Helsinki. Patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgments: the authors would like to express their gratitude to the respondents of this study for their valuable support and to the Conselho Nacional de Desenvolvimento Científico e Tecnólogico, the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro, and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior for pro- viding funding for this research. Received: 10 January 2024. Accepted: 14 March 2024. Early access: 28 March 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2024 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2024; 12:12376 doi:10.4081/hls.2024.12376 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 326] [Healthcare in Low-resource Settings 2024;12:12376] Non -co mmerc ial us e o nly ed the need for greater amplification and recognition of all nurses’ actions to better meet patient care needs.7 International healthcare delivery continues to face several problems, including population growth that is not accompanied by increases in health care and a shortage of financial resources in developing countries.8 The intrinsic factors affecting this correlation, in most cases, are work- load, training, and internships, which are modifiable factors that elucidate the profile of the professional for the exercise of the func- tion.9 As part of a multidisciplinary team (MDT), nurses propose their productive capacity as ideal, enabling them to act on a man- agement model.10,11 In this way, nurses seek to guarantee their labor rights and job satisfaction, based on production and quality of care (QoC). Through more appropriate resource allocation, the MDT approach has increasingly been seen as one of the most valuable working models for the possibility of allocating resources more appropriately and contributing to better outcomes. A shift to the practice of MDTs in nursing care occurred in response to skill mix changes in both primary care and critical care settings.12–15 However, there is a need for greater involvement of nurses in all fields as members of MDTs, as this will directly affect QoC and patient safety. In recent years, research using diverse methodological approaches has led to significant progress in healthcare research.13– 15 Teamwork must involve people with diverse skills and knowl- edge to facilitate the achievement of the team’s and institution’s goals. In the context of nursing, both multidisciplinary and inter- professional work should ultimately aim to refine nurse education standards and improve patient safety.16–18 Importantly, the WHO emphasizes that MDTs are of paramount importance in health care reform that calls for comprehensive and cost-effective care.19 Understanding and emphasizing the importance of MDTs in the public and private sectors will contribute to more effective use of knowledge activities in teamwork, which will result in higher QoC.1,4 Based on the idea of MDT, there is a growing demand among nurses for specialized training and certification because of the need to obtain skills for qualified development of patient care.20 These skills can provide confidence in the execution of nurses’ tasks in practice and contribute to their competitiveness in the job market. In the search for a better job, nurses are motivated to add specialties to their curriculum vitae to increase their potential salaries and to be eligible for a greater number of positions.20 It should be noted that nurses, through the indices and curricular guidelines, feel the need for continuing education focused on spe- cialization so they can acquire the knowledge and skills to meet the needs of various areas of patient care, and thus be able to act within the scope of the public health system in an ethical, reflective, and critical way.9 A study with 19 nurses in the United Kingdom showed some difficulties in implementing teamwork, including varying degrees of competence to act as a team member and divergent individual perceptions about teamwork.21 Thus, the evaluation of nurses’ per- ceptions about MDT is important to understand how they look at teamwork since nurses are the ones who provide most of the patient care.11 More specifically, the perceptions of specialist nurs- es can contribute greatly to understanding the process of multidis- ciplinary team evolution, considering that they have greater knowl- edge and the possibility of implementing that knowledge.1,2 Thus, the present study aimed to explore nurses’ perceptions of multidis- ciplinarity in the field of specialist nurses and to evaluate how spe- cialization is associated with better patient care and nurses’ age in a low-resource setting in Southeast Brazil. Materials and Methods Study design and participants In the period between November 2021 and March 2022, a cross-sectional study using questionnaires was carried out to assess the perceptions of specialized nurses. Nurses aged ≥18 years of both sexes who had at least one specialization in nursing and worked at the Regional Health Superintendence of Manhuaçu located in Zona da Mata Mineira, Minas Gerais, Brazil, were included. The Zona da Mata Mineira is a geographic region that covers an area of approximately 35.7 thousand km² and a popula- tion of more than 2 million inhabitants. Those who did not return the questionnaire (n=11) and provided incomplete survey respons- es (n=4) were excluded. Variable, instrument, and data collection A questionnaire containing sociodemographic information and nurses’ areas of activity was used. In addition, the participants answered 10 questions focused on specializations, MDTs, and their importance in the field of health. The questions were constructed based on the research objectives. We used a five-point Likert scale containing the following options: i) extremely important, very important, important, slightly important, not necessary; ii) very unlikely, unlikely, neutral, likely, very likely; or iii) strongly agree, agree, neutral, disagree, strongly disagree.22 Before submission, we contacted the Regional Health Superintendence of Manhuaçu to ask for potential participants’ email addresses. An online questionnaire (Google Forms) was sent as a link in an initial email, which contained an invitation to par- ticipate in the research. Professionals could choose to participate in the research or decline after reading the consent form, which guar- anteed anonymity. If they accepted, the online survey was avail- able to them. This method was chosen as being inexpensive, time- saving, and achievable without much effort.23 Data analysis The results were tabulated via Excel, and data analysis was performed through a preliminary analysis of the participants’ pro- files and, secondarily, the creation of associations between the answers given by them. The inferential analysis was performed using Kendall’s tau-b (τb) correlation coefficient to analyze the association between nurses’ responses to multidisciplinarity. This coefficient is a nonparametric dependence measure used in cross- tabulation to measure the association between two ordinal vari- ables; moreover, Kendall’s τb has several advantages over Pearson and Spearman’s r, including maintaining adequate control of type I errors and providing a clear interpretation.24 The values of τb vary between -1 and 1, and the closer to -1 or 1, the stronger the associ- ation between the two variables. The significance determination criterion adopted was a p<0.05. SAS 6.11 software (SAS Institute, Inc., Cary, NC, USA) was used for statistical data analysis. Ethical clearance The study was approved by the Research Ethics Committee of the Centro Universitário Augusto Motta under the number CAAE- 50714121.2.0000.5235, and all participants signed the consent form. The study followed the recommendations for research in humans as per the Declaration of Helsinki. Article [Healthcare in Low-resource Settings 2024;12:12376] [page 327] Non -co mmerc ial us e o nly Results Seventy specialty nurses were enrolled in the study, and most were aged between 20-40 years (n=39, 84.3%), women (n=42, 60%) and white (n=33, 47.2%). Most participants were single (n=37, 52.9%) and had no children (n=36, 51.4%). Most specialty nurses worked in a hospital unit (n=35, 50%) and the field of fam- ily health (n=22, 31.4%). The general characteristics of the partic- ipants are shown in Table 1, while the distribution of the partici- pants regarding the area of nursing practice is shown in Figure 1. Regarding the importance of having specialization in nursing, 80% of the participants (n = 56) answered that it was extremely or very important. When nurses were asked if they were opinion for- mers for the population, more than half of them (n=36, 51.4%) responded “very likely” and, at the other extreme, less than 10% of them (n=6) responded “very unlikely.” Regarding the statement that nurses should meet certain qualifications to provide patients with a higher QoC, more than 75% of the participants (n=53) responded that they strongly agreed with this statement. When the participants were asked whether multidisciplinarity in nursing is essential to the treatment and continued care of the patient, more than 75% of the participants (n=53) also responded that they strongly agreed with this statement. Regarding the prompt about the unreliability of health information on the internet, 70% of the participants (n=49) answered that they agreed or strongly agreed. Regarding the statement that unqualified nurses are self-indul- gent and cause distrust among patients, 50% (n=35) said they were neutral or disagreed, and 50% (n=35) agreed or completely agreed. Regarding the statement that there is a considerable difference between specialized nurses and nonspecialized nurses, more than half of the participants (n=37, 52.8%) disagreed or completely dis- agreed. Regarding the statement that specialized nurses can pro- vide better patient care because they are more qualified, more than 70% of the participants (n=51) answered that they agreed or strongly agreed. Regarding the statement that nonspecialized nurs- es cannot meet the necessary demands required at work, almost 80% (n=55) responded that they disagreed or completely dis- agreed. Regarding the statement that the work team needs a nurse capable of exercising leadership and that he or she must have spe- cialization for this performance, 60% of the participants (n=42) answered that they disagreed or completely disagreed. The distri- bution of participants’ assessments of specialization and multidis- ciplinarity in nursing is shown in Table 2. Table 3 shows a significant association between the impor- tance of having specialization in nursing and the fact that special- ized nurses can provide better patient care because they are more qualified using Kendall’s τb (τb=0.293, p=0.002); this implies that having specialization in nursing facilitates better patient care according to the respondents. Table 4 shows a significant associa- tion between the considerable difference between specialist nurses vs. non-specialist nurses and the age range of respondents using Kendall’s τb (τb=-0.272, p=0.004); this implies that younger respondents tend to agree that there are considerable differences between specialist nurses and nonspecialist nurses, while older respondents tend to disagree that there are considerable differences between specialist nurses and nonspecialist nurses. Discussion The main findings of the present study were that among spe- cialized nurses, there was a high prevalence of young nurses who were female, single, without children, and working in the area of family health. Eighty percent of them believe in the importance of specialization in nursing, while more than half strongly believe it provides support for opinion formation among the population. More than 75% of specialized nurses say that they can provide higher QoC and that MDTs are essential for improvement in patient care. Seventy percent of specialized nurses believe that health information on the internet is not very reliable. However, most of this group of nurses disagreed that there is a considerable difference between specialized and nonspecialized nurses and that specialization is essential for the exercise of leadership. There is a relationship between the importance of specialization and better patient care and between valuing the fact of being a specialized nurse and age group. Article Figure 1. Distribution of participants according to the area of nurs- ing practice. Table 1. General characteristics of the participants (n=70). Variable Number (%) Age group 20-30 years 28 (40) 31-40 years 31 (44.3) 41-50 years 10 (14.3) 51-60 years 1 (1.4) Sex Male 28 (40) Female 42 (60) Race/ethnicity White 33 (47.2) Brown 22 (31.4) Black 15 (21.4) Marital status Single 37 (52.9) Married 33 (47.1) Number of children None 36 (51.4) One 25 (35.7) Two 9 (12.9) Field of activity Hospital unit 35 (50) Family health strategy 15 (21.4) Basic health unit 11 (15.7) Emergency service 4 (5.7) Ambulance station 3 (4.3) Other 2 (2.9) [page 328] [Healthcare in Low-resource Settings 2024;12:12376] Non -co mmerc ial us e o nly Article Table 2. Distribution of participants' assessments of specialization and multidisciplinarity in nursing. Variable Number (%) Having a specialization in nursing Extremely important 28 (40) Very important 28 (40) Important 12 (17.1) Little important 2 (2.9) Not necessary 0 (0) Nurses are opinion formers for the population Very unlikely 6 (8.6) Unlikely 10 (14.3) Neutral 7 (10) Likely 11 (15.7) Very likely 36 (51.4) Nurses should meet certain qualifications to provide patients with a higher quality of care Strongly agree 53 (75.7) Agree 17 (24.3) Neutral 0 (0) Disagree 0 (0) Strongly disagree 0 (0) The multidisciplinarity in nursing is essential to the treatment and continued care of the patient Strongly agree 53 (75.7) Agree 17 (24.3) Neutral 0 (0) Disagree 0 (0) Strongly disagree 0 (0) The unreliability of health information on the internet Strongly agree 20 (28.6) Agree 29 (41.4) Neutral 7 (10) Disagree 10 (14.3) Strongly disagree 4 (5.7) Unqualified nurses are self-indulgent and cause distrust among patients Strongly disagree 0 (0) Disagree 25 (35.7) Neutral 10 (14.3) Agree 23 (32.9) Strongly agree 12 (17.1) There is a considerable difference between specialized nurses and nonspecialized nurses Strongly disagree 15 (21.4) Disagree 22 (31.4) Neutral 9 (12.9) Agree 21 (30) Strongly agree 3 (4.3) Specialized nurses can provide better patient care because they are more qualified Strongly agree 21 (30) Agree 30 (42.9) Neutral 5 (7.1) Disagree 14 (20) Strongly disagree 0 (0) Nonspecialized nurses cannot meet the necessary demands required at work Strongly disagree 28 (40) Disagree 27 (38.6) Neutral 8 (11.4) Agree 7 (10) Strongly agree 0 (0) The work team needs a nurse capable of exercising leadership and he or she must have specialization for this performance Strongly disagree 15 (21.4) Disagree 27 (38.6) Neutral 11 (15.7) Agree 15 (21.4) Strongly agree 2 (2.9) [Healthcare in Low-resource Settings 2024;12:12376] [page 329] Non -co mmerc ial us e o nly In our study, there was a higher prevalence of nurses in the 20-40 age group, which indicates that younger nurses are increas- ingly seeking to specialize. We also observed a predominance of females in a ratio of 6:4. In this sense, it is important to highlight the phenomenon of “feminization”, which is understood as a situ- ation composed of the relative increase in females in a given area of work, occurring mainly in health-oriented professions.25 Evaluating strategies to improve quality of life (QoL) at the end of life in an MDT, Zadeh et al.26 also showed a predominance of young nurses in their sample. According to Yanoullas,25 this phe- nomenon is partly explained by the transformation of the idea of work, thus adhering to the principle of qualified labor focused on social prestige that currently tends to remodel the work system. Our findings also showed that almost a third of the participants were in the area of family health. According to Corrêa et al.,27 pri- mary care focused on care opens up a range of possibilities for nurses based on knowledge about the work and the population. In a way, the health–disease approach, within the scope of nurses’ knowledge, offers ways to improve patient care, especially through the family health strategy that continuously improves ethical prac- tices for health care. In line with our findings, a Spanish study showed that among specialized nurses, 50.2% worked in primary care, 24.9% in hospitals, and 22.7% in mental health.28 In relation to chronic and complex care, Wilkes et al.29 showed that primary care nurses in multidisciplinary teams can achieve a more effective interdisciplinary approach. By becoming specialists in their area of expertise, nurses demonstrate QoC (as they have deeper theoretical knowledge) and modify the conditions of the territory, bringing local and sustainable development with their professional evolu- tion.30 In our study, most participants believed in the importance of specialization in nursing and that it provides support for forming the population’s opinion. In this sense, there is a need to modify and improve situations aimed at building an integrated, complex, polysemic, multifaceted, and innovative vision.31 Along the same lines, two-thirds of our participants stated that specialized nurses can provide higher QoC and, therefore, improve nurse-patient rela- tions.32 Notably, having an MDT has a positive effect on job satis- faction, team efficiency, and care delivery. In addition, nurse lead- ers can drive aspects of highly functional teams by improving team orientation, trust, and supportive behaviors.11 The vast majority of respondents in our study believe that MDTs are essential for improving the continuum of QoC. From the analyses, one can have a better idea of the importance of the spe- cialty, especially when it is focused on MDT, modeling the nurses’ profile so that its consistency goes beyond the old ideal of being just another profession. In this sense, there is a growing demand for the multidisciplinarity of professional nurses who, through qualification, increase their value as MDT members.31 The multi- disciplinary evolution of nursing through specialties also enhances patient care practices.33 Evaluating 84 patients diagnosed with ter- minal cancer, Liu et al.34 recently showed that, compared to routine nursing, an MDT associated with palliative care reduced patients’ psychiatric disorders and improved their QoL. Along the same lines, another recent study showed that the MDT model with nurs- ing leadership for transplant recipients reduced complications, reduced hospital stays, and saved costs.35 Thus, promoting, empha- sizing, and continuing professional training qualifies the work of specialist nurses and enables the development of more humanized care for the patient.30,36 Establishing a teamwork training (TT) pro- gram is a crucial approach, although the fundamentals for TT are well known and its need is obvious in the nursing environment. TT is a critical part of any comprehensive security plan as it improves teamwork and communication to achieve the best possible results.37 Despite all the appreciation that the participants pointed out about specialization, most of them disagreed that there is a consid- erable difference between the specialized nurse and the nonspecial- ized nurse and that specialization is essential for the exercise of leadership. Patient care in its entirety must seek harmony between the biological-psychological-social dimensions, the transfer of knowledge and teamwork, and constant health surveillance.38 Taken together, these factors may explain, at least in part, our Article Table 3. Association between the importance of having specialization and the fact that specialized nurses can provide better patient care. Variable Specialized nurses can provide better patient care because they are more qualified p Strongly agree Agree Neutral Disagree Number (%) Number (%) Number (%) Number (%) Having specialization in nursing Extremely important 12 (57.1) 13 (43.3) 1 (20) 2 (14.3) 0.002 Very important 7 (33.3) 11 (36.7) 4 (80) 6 (42.9) Important 2 (9.5) 4 (13.3) 0 (0) 6 (42.9) Little important 0 (0) 2 (6.7) 0 (0) 0 (0) Table 4. Association between specialist nurses vs. non-specialist nurses and the age range of respondents. Variable Age group p 20-30 years 31-40 years 41-50 years 51-60 years Number (%) Number (%) Number (%) Number (%) There is a considerable difference between specialist nurses vs non-specialist nurses Strongly disagree 5 (17.9) 8 (25.8) 2 (20) 0 (0) 0.004 Disagree 4 (14.3) 11 (35.5) 7 (70) 0 (0) Neutral 4 (14.3) 4 (12.9) 0 (0) 1 (100) Agree 12 (42.9) 8 (25.8) 1 (10) 0 (0) Strongly agree 3 (10.7) 0 (0) 0 (0) 0 (0) [page 330] [Healthcare in Low-resource Settings 2024;12:12376] Non -co mmerc ial us e o nly results. Notably, teamwork protocols can help define the impor- tance of specialization and interventions in the professional net- work.15 When the associations were evaluated, we observed that nurses understand the importance of a multidisciplinary specializa- tion and, through this, perform better work, based on the idea that the chosen area improves their performance. With such an associ- ation, it is necessary to understand the constant need for profes- sional improvement, which allows nurses to perform their work with more dexterity and safety.39 It is worth mentioning that many specialists find it difficult to exercise their profession accordingly due to the lack of job descriptions and identification of competen- cies during the recruitment and promotion processes. Therefore, it is essential to create a catalog of specific positions for each of the specialties to meet nurses’ expectations and enhance progress in QoC and patient safety. We experience a more technological world, where professionals seek to qualify themselves every day, in the job market. We observed an association between the need for specialization and younger age groups. Young nurses already carry the burden of being in a competitive job market, and they seek to improve their marketability through specialization in nursing. Thus, the younger the nurse, the more he or she understands the need to specialize and that a specialist nurse, through the practice acquired in training, has the necessary qualifications to care for the patient. This relationship also implies that the older the profession- al is, the less he or she understands the need for specialization in the field of nursing.40 Some limitations of our study should be noted. First, the number of participants was relatively small, although we only included specialist nurses. Secondly, our assess- ment was made subjectively using a questionnaire; therefore, the use of objective measures in future studies may deepen knowledge about the importance of MDTs in the field of nursing work and how MDTs interfere with nurses’ motivation. Based on the profile of nurses working in a region in the interior of Brazil, our study can serve as a starting point for a better understanding of the diffi- culties of these health professionals, especially concerning special- ization in nursing. Conclusions Our study shows a current tendency for specialized nurses to be young, female, and single, with a predilection for the area of family health. In general, they believe in the importance of special- ization, especially in the possibility of providing a higher QoC and job performance. There is an association between the importance of having specialization and the best patient care, and the younger the nurse is, the greater the appreciation of the nursing specializa- tion. By defending the idea of MDT, we enter into a typical debate in the work scenario of a nurse, evidenced by the QoC proposed by the professional who qualifies through a specialty. 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