Abstract

The paper discusses the Portuguese Health System that has adopted the Beveridge model, which is based on the financing of health services by taxpayers' income, based on a public system, where the right to health is independent of work and employment. Nursing education is structured in Pre-Graduate Education – Degree; Master and Doctorate in Nursing Sciences and Nursing. The competency of the generalist nurses refers to the professional performance showing the effective application of knowledge and skills, which allows them to make a clinical judgment and decide. The exercise of competencies is based on the interpersonal relationship between the nurse and the individual client or group; decision-making based on scientific evidence, clinical judgment based on the needs of individual or group care, prescribed nursing interventions considering the safety of care and the client, early detection of the real or diagnostic potentials seeking resolution or minimization of consequences, by the values of the patients, as well as respect and professional regulation that establish good practice.

Key words
Health Policy; Primary Health Care; Nursing

Introduction

Portugal (mainland and the two archipelagos) currently has a total of 10.3 million inhabitants, concentrated mainly in the metropolitan areas of Lisbon, Porto, and the coast, and the inland region is the most desertified part of the country¹1 Portugal. Ministério da Saúde. Retrato da Saúde 2018 [livro na Internet]. [acessado 2018 Mar 21]. Lisboa: Ministério da Saúde; 2018. Disponível em: http://www.insa.min-saude.pt/conheca-o-retrato-da-saude-em-portugal-2018/
http://www.insa.min-saude.pt/conheca-o-r... .

As of 1974, a remarkable human, social, and economic development was scaled-up, especially after joining the European Economic Community (1986) and the Eurozone (1999), positively influencing the determinants of health. At the same time, an increased mean life expectancy was noted, with women and men hiking from 71.4 years and 64.8 years, respectively, in 1974, to 83.4 and 77.8 years, respectively, in 2017, coinciding with European Union (EU) values (from 28 countries in 2017)²2 Instituto Nacional de Estatística (INE). Conta Satélite da Saúde 2016-2019 [Internet]. 2019 [acessado 2018 Mar 21]. Disponível em: https://www.sns.gov.pt/noticias/2019/07/05/ine-divulga-conta-satelite-da-saude
https://www.sns.gov.pt/noticias/2019/07/... . Women have higher longevity than men but are more affected by musculoskeletal disorders, depression, and obesity³3 Portugal. Ministério da Saúde. Serviços e Estabelecimentos do Serviço Nacional de Saúde [Internet]. 2018 [acessado 2018 Mar 21]. Disponível em: https://www.sns.gov.pt/sns/servico-nacional-de-saude/
https://www.sns.gov.pt/sns/servico-nacio... .

Better living conditions, coupled with a greater supply of quality health services and a decreased prevalence of some diseases, contributed to prolonging the life of the Portuguese. This has resulted in an aging population, where life expectancy at 65 years of age in 2017 was 19.5 years on average for both genders, with 153.2 older adults per 100 young people⁴4 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. State of Health in the EU: Portugal: Perfil de Saúde do País 2017 [Internet]. Paris: OECD Publishing, Brussels: European Observatory on Health Systems and Policies; 2017. [acessado 2018 Mar 21]. Disponível em: http://dx.doi.org/10.1787/9789264285385-pt
http://dx.doi.org/10.1787/9789264285385-... .

Concerning access, the main obstacle is geographical disparities that interfere with meeting unmet medical care needs, but similar to the EU average. Health care expenditure is unequal and far below other EU countries. In 2015, Portugal spent 1,989 euros per capita on health care, about 30% below the EU average (2,797 euros). These expenses amount to 9% of GDP, with the EU average standing at 9.9%. Public funding covers about two-thirds of expenditure, but direct payments have increased and burdened household spending. However, vulnerable groups are exempt from copayments, thus ensuring access to health services⁵5 Escoval A, Matos T, Ribeiro R, Santos ATL. Contratualização em Cuidados de Saúde Primários: Horizonte 2015/2. Fase 5: Relatório Final [relatório na Internet]. 2010 [acessado 2018 Mar 21]. Disponível em: http://portaisars.azurewebsites.net/wp-content/uploads/2017/01/contratualizacao_csp.pdf
http://portaisars.azurewebsites.net/wp-c... .

Portugal has one of the lowest avoidable hospitalization rates in the EU, and health care-sensitive mortality rates, albeit with gender differences, are in line with EU averages⁴4 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. State of Health in the EU: Portugal: Perfil de Saúde do País 2017 [Internet]. Paris: OECD Publishing, Brussels: European Observatory on Health Systems and Policies; 2017. [acessado 2018 Mar 21]. Disponível em: http://dx.doi.org/10.1787/9789264285385-pt
http://dx.doi.org/10.1787/9789264285385-... . Several reforms have been made to enhance the efficiency and transparency of the health system, such as the implementation of effective health measures and policies to ensure financial sustainability, which is essential to any health system⁵5 Escoval A, Matos T, Ribeiro R, Santos ATL. Contratualização em Cuidados de Saúde Primários: Horizonte 2015/2. Fase 5: Relatório Final [relatório na Internet]. 2010 [acessado 2018 Mar 21]. Disponível em: http://portaisars.azurewebsites.net/wp-content/uploads/2017/01/contratualizacao_csp.pdf
http://portaisars.azurewebsites.net/wp-c... .

The Portuguese Health System

The Health System concept is comprehensive. The World Health Organization (WHO)⁶6 World Health Organization (WHO). The world health report 2008: primary health care: now more than ever. Genebra: WHO; 2008. affirms it is the possibility of realizing “all activities whose essential purpose are the promotion, recovery or maintenance of health”⁶6 World Health Organization (WHO). The world health report 2008: primary health care: now more than ever. Genebra: WHO; 2008.(p.40). Andrade⁷7 Andrade AC. A Regulação do Sistema de Saúde Português: Contribuição para um novo paradigma na prestação de cuidados de saúde. e-Pública [periódico na Internet]. 2016 [acessado 2018 Mar 21]; 3(3):201-221. Disponível em: http://www.scielo.mec.pt/pdf/epub/v3n3/v3n3a10.pdf
http://www.scielo.mec.pt/pdf/epub/v3n3/v... argues it is a “functional system directed to the provision of health care, encompasses the National Health Service (SNS) and the establishments under the Ministry of Health, just as one of the elements, along with private and social entities (for-profit or not-for-profit)”⁷7 Andrade AC. A Regulação do Sistema de Saúde Português: Contribuição para um novo paradigma na prestação de cuidados de saúde. e-Pública [periódico na Internet]. 2016 [acessado 2018 Mar 21]; 3(3):201-221. Disponível em: http://www.scielo.mec.pt/pdf/epub/v3n3/v3n3a10.pdf
http://www.scielo.mec.pt/pdf/epub/v3n3/v... (p.209).

World health systems can be designed based on specific issues and the articulation of three components that will provide us with different models: Political (Management Model), Economic (Financing Model) and Medical (Care Model)⁸8 Nunes E. Principais sistemas de saúde no mundo [Internet]. 2015 [acessado 2018 Mar 21]. Disponível em: http://www.rets.epsjv.fiocruz.br/sites/default/files/arquivos/biblioteca/principais_sistemas_de_saude_do_mundo.pdf
http://www.rets.epsjv.fiocruz.br/sites/d... . The Beveridge model (based on the UK model) was established in Portugal, which is based on the financing of health services by taxpayers' income, building on a public system where the right to health is independent of work and employment.

However, the progressive tax system concerning healthcare becomes regressive as it has a significant dependence on indirect taxes and household budget overload (which was 27.8% in 2016) and has been increased to allow financial sustainability²2 Instituto Nacional de Estatística (INE). Conta Satélite da Saúde 2016-2019 [Internet]. 2019 [acessado 2018 Mar 21]. Disponível em: https://www.sns.gov.pt/noticias/2019/07/05/ine-divulga-conta-satelite-da-saude
https://www.sns.gov.pt/noticias/2019/07/... .

In 1990, in Portugal, the Basic Law of Health emerged, which presents the concept of a health system that is “established by the SNS and all public entities that perform health promotion, prevention and treatment activities, as well as by all private entities and self-employed professionals who agree with the former to provide all or some of those activities”, aiming to protect the health of people living in Portugal⁹9 Portugal. Ministério da Saúde. Assembléia da República. Lei nº 48, de 24 de agosto de 1990. Lei de Bases da Saúde [documento na Internet]. Diário da República; 1990. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/pesquisa/-/search/574127/details/normal?p_p_auth=zt2dAYbd
https://dre.pt/pesquisa/-/search/574127/... .

The Portuguese health system currently consists of a combination of both public and private funding, and as a functional system includes the SNS – funded mostly by taxes, and establishments, under the jurisdiction of the Ministry of Health, private and social for-profit and nonprofit entities. Moderating fees are also applied for visits, urgent services, home visits, and complementary diagnosis and therapy means, but about 60% of the population is exempt from their payment⁴4 Organisation for Economic Co-operation and Development (OECD), European Observatory on Health Systems and Policies. State of Health in the EU: Portugal: Perfil de Saúde do País 2017 [Internet]. Paris: OECD Publishing, Brussels: European Observatory on Health Systems and Policies; 2017. [acessado 2018 Mar 21]. Disponível em: http://dx.doi.org/10.1787/9789264285385-pt
http://dx.doi.org/10.1787/9789264285385-... (Figure 1).

The Health Regulatory Authority (ERS) is an independent public body that regulates the activity of healthcare providers, created by Decree-Law Nº 309/2003, of December 10. In 2016, the National Health Council, an independent body that gathers the main stakeholders in the health sector, was established. It acts as a government advisory body in reaching consensus, as well as producing studies and recommendations on health policy issues. Private health facilities and pharmacies are not integrated into the SNS.

The Ministry of Health is the government department that defines and conducts the National Health Policy, ensuring the sustainable application and use of resources and the evaluation of its results. It should regulate, finance, guide, follow-up, evaluate, audit, and inspect the SNS¹⁰10 Portugal. Ministério da Saúde. Decreto-Lei nº 124, de 29 de dezembro de 2011. Aprova a Lei Orgânicado Ministério da Saúde [documento na Internet]. Diário da República; 2011. [acessado 2018 Mar 21]. Disponível em: https://data.dre.pt/eli/dec-lei/124/2011/12/29/p/dre/pt/html
https://data.dre.pt/eli/dec-lei/124/2011... (Figure 2)

Hierarchically, the Ministry of Health has direct administration of services: General Health Secretariat (SG), which provides technical and administrative support to the other offices of the Ministry; General Inspectorate of Health Activities (IGAS), which has the task of auditing, supervising and acting disciplinarily in the provision of health care, whether from the public sector or private or social entities; General Directorate of Health (DGS), which plans, regulates, directs, coordinates and supervises all health promotion and disease prevention activities, as well as lays down the technical conditions for the appropriate provision of care, and is responsible for public health programs, health quality, epidemiological surveillance, health statistics; Addictive Behavior and Dependence Intervention Service (SICAD), which promotes the reduction of psychoactive substance use, the prevention of addictive behaviors and reduction of dependence¹¹11 Portugal. Ministério da Saúde. Decreto-Lei nº 28, de 22 de fevereiro de 2008. Estabele o regime da criação, estruturação e funcionamento dos agrupamentos de centros de saúde do Serviço Nacional de Saúde [documento na Internet]. Diário da República; 2008. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/247675
https://dre.pt/application/conteudo/2476... .

Portuguese Private Health Sector

The Portuguese private initiative is highlighted in the coverage and quality of health services, both from a complementary perspective to the SNS and as an additional one.

The conventions, conclusion of agreements, and contracting of services are provided for under the Basic Law of Health (1990). Other areas of cooperation between the public and private sectors were established: the program to combat surgical waiting lists - SIGIC (Integrated Management System for Surgical Subscribers), the National Network of Integrated Continuing Care (RNCCI) and the Public-Private Partnerships. Private (PPP)¹²12 Mateus A, Ramalho E, Oliveira H, Rodrigues H, Ferreira R. Setor Privado da Saúde em Portugal - Versão executiva [Internet]. AM&A; 2017. [acessado 2018 Mar 21]. Disponível em: https://fronteirasxxi.pt/wp-content/uploads/2018/02/Estudo-Sector_Privado_da_Sa%C3%BAde_em_Portugal.pdf
https://fronteirasxxi.pt/wp-content/uplo... .

About 40% of the Portuguese population beneficiary of the SNS has at the same time a public health subsystem (for example: State Civil Servants Disease Assistance – ADSE, Military Disease Assistance – ADM, Health Subsystem of the Social Services of the Ministry of Justice – SSMJ), private health subsystem or (individual or group) health insurance, geared to private providers, which reinforces the current relevance of the private sector in the national health framework. Private supply has increased and is used to overcome gaps or weaknesses in the public sector, such as inadequate coverage, provision of complementary diagnostic and therapeutic means, better comfort level in hospitalization services, and aesthetic care, among others¹²12 Mateus A, Ramalho E, Oliveira H, Rodrigues H, Ferreira R. Setor Privado da Saúde em Portugal - Versão executiva [Internet]. AM&A; 2017. [acessado 2018 Mar 21]. Disponível em: https://fronteirasxxi.pt/wp-content/uploads/2018/02/Estudo-Sector_Privado_da_Sa%C3%BAde_em_Portugal.pdf
https://fronteirasxxi.pt/wp-content/uplo... .

National Health Service (SNS)

In the 1970s, a series of transformations occurred in Portuguese society that led to the remarkable reforms in the Portuguese Health System. Decree-Law Nº 413/71 of September 27 (Organic Law of the Ministry of Health) establishes the new National Health System as a unified health system (public and private – including Misericórdias and other private or social entities). Integrating the Medical-Social Welfare Services, the right to health of all citizens was recognized, and for the first time, the role of the State as responsible for health policies and their implementation was identified. As a result of this law, Decree-Law Nº 414/71 emerges and establishes the professional careers of the health personnel¹³13 Portugal. Ministério da Saúde. Decreto-Lei nº 414, de 22 de outubro de 1991. Visa definir o regime legal da carreira dos técnicos superiores de saúde dos serviços e estabelecimento do Ministério da Saúde e da Santa Casa Misericórdia de Lisboa [documento na Internet]. Diário da República; 1991. [acessado 2018 Mar 21]. Disponível em: https://data.dre.pt/eli/dec-lei/414/1991/10/22/p/dre/pt/html
https://data.dre.pt/eli/dec-lei/414/1991... .

Thus, two functional organizations were created from the various districts, namely, Health Centers (Primary Care) and Hospitals. The Ministry of Health restructured the central, regional, district, and local services, guiding, through the General Directorate of Health and Hospitals, the whole health policy¹⁴14 Baganha MI, Ribeiro JS, Pires S. O Sector da Saúde em Portugal: funcionamento do sistema e caracterização sócio-profissional [Internet]. [acessado 2018 Mar 21]. Disponível em: https://www.ces.uc.pt/publicacoes/oficina/182/182.pdf
https://www.ces.uc.pt/publicacoes/oficin... . This reform became known as the Gonçalves Ferreira reform, and this was the first draft of the public health model. However, the SNS was only founded in 1979, with the primary characteristics that persist to this day.

Resulting from the amendment of the Portuguese constitution (1976), which states that all citizens have the right to receive health care and the Health Law (1979), the National Health Service was founded within the Ministry of Social Affairs to ensure the right to health protection under the terms of the Constitution. The SNS is free and encompasses all integrated health care, including health promotion and surveillance, disease prevention, diagnosis, treatment, and medical and social rehabilitation. It has administrative and financial autonomy with a central, regional, and local decentralized structure that provides primary (PHC) and differentiated (hospitals and specialized institutions) care¹⁶16 Portugal. Ministério da Saúde. Lei nº 56, de 15 de Setembro de 1979. Serviço Nacional de Saúde [documento na Internet]. Diário da República; 1979. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/web/guest/pesquisa/-/search/369864/details/normal?_search_WAR_drefrontofficeportlet
https://dre.pt/web/guest/pesquisa/-/sear... .

Along the way, it has modified and retains the values underlying the establishment but faces new challenges. Citizens have health-related rights, and the responsibility for individual health lies primarily with citizens who must defend and promote it. The SNS is characterized by the universality, provision, or guarantee of global care, a tendency towards free and equitable access to care.

In order to achieve this mission, the healthcare services and public entities, namely the Health Center Clusters (ACES) (dependent on the Regional Health Administrative Offices), the hospitals (regardless of their name) and the Local Health Units (ULS), must follow directives issued by the General Directorate of Health (DGS). These guidelines derive from the National Health Plan (PNS) with an indication of priority programs to be worked on.

The PNS scheme extension to 2020 is shown in Figure 3.

At the local level, in collaboration with the ARS and ACES, and with the possible participation of the municipalities (administrative divisions of the territory), the local health plans are prepared, aligned with the PNS and meet the determinants of their region that influence individual, family and community health¹⁷17 Portugal. Ministério da Saúde. Plano Nacional de Saúde em revisão e extensão a 2020 [Internet]. 2015 [acessado 2018 Mar 21]. Disponível em: http://pns.dgs.pt/files/2015/06/Plano-Nacional-de-Saude-Revisao-e-Extensao-a-2020.pdf.pdf
http://pns.dgs.pt/files/2015/06/Plano-Na... .

The perspective of primary health care is realized in the SNS through a network of community health centers, with national coverage and as a result of a proximity policy, and are distributed across residential territories. The ACES consist of several functional units, which integrate one or more health centers¹¹11 Portugal. Ministério da Saúde. Decreto-Lei nº 28, de 22 de fevereiro de 2008. Estabele o regime da criação, estruturação e funcionamento dos agrupamentos de centros de saúde do Serviço Nacional de Saúde [documento na Internet]. Diário da República; 2008. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/247675
https://dre.pt/application/conteudo/2476... . These functional units are Family Health Units (USF), Customized Health Care Units (UCSP), Community Care Units (UCC), Public Health Units (USP), and Shared Assistance Resources Units (URAP).

These basic units provide health care to the population in the areas of general and family medicine, child and youth health, maternal health, public health and social services, as well as a set of daily activities, such as medical and nursing appointments, home visits, among others, which will respond to the specific needs of the population they serve¹⁸18 Ministério da Saúde. Reforma dos Cuidados de Saúde Primários Plano Estratégico 2010-2011 [Internet]. 2007 [acessado 2018 Mar 21]. Disponível em: https://www.sns.gov.pt/wp-content/uploads/2016/02/Plano-EstratC¸gico-2010-2011-MCSP.pdf
https://www.sns.gov.pt/wp-content/upload... .

Nursing in Portugal

Nursing is a profession that aims to provide care to humans in various contexts throughout the life cycle. Nurses are professional holders of the Nursing course, legally recognized by the Regulation of Professional Nursing Practice (REPE), in its Chapter II, Article 4, and of the professional title awarded by the Nursing Association (OE) that recognizes human, scientific and technical skills for the provision of Nursing care¹⁹19 Portugal. Dercreto-Lei nº 161, 4 de setembro de 1996. Regulamento do exercício profissional dos enfermeiros - REPE [documento na Internet]. Diário da República; 1996. [acessado 2018 Mar 21]. Disponível em: https://www.ordemenfermeiros.pt/arquivo/AEnfermagem/Documents/REPE.pdf
https://www.ordemenfermeiros.pt/arquivo/... .

According to the OE, in December 2018, 73,912 registered nurses were working in the following contexts: General Care 31,552; Specialized Care 2,970; Advisory/Consultancy 89; Education and Research 357; Training 275; Management 1,950; Other 564; Unknown 36,155, and were always mostly female. Regarding distribution by specialty: Community Nursing 2,869; Rehabilitation Nursing 4,110; Child and Pediatric Health Nursing 2,663; Maternal and Obstetric Health Nursing 2,917; Mental and Psychiatric Health Nursing 2,088; Medical-Surgical Nursing 4.035. They are mostly Portuguese, although some nurses are from other nationalities; except for Oceania, all continents are represented, with Spain in second and Brazil in third. Concerning the sector of activity, they work in ACES – Primary Health Care 7,836, in differentiated care – Hospitals 32,834; in clinics/laboratory 1,051; other institutions 1,169; unknown 30,503, and in higher education in Nursing 519²⁰20 Ordem dos Enfermeiros (OE). Ensino de enfermagem e a sua potencial integração no subsistema universitário [Internet]. 2017 [acessado 2018 Mar 21]. Disponível em: https://www.ordemenfermeiros.pt/arquivo/membros/Documents/01.08.2017%20-%20Tomada%20de%20posi%C3%A7%C3%A3o-%20Ensino%20de%20Enfermagem.pdf
https://www.ordemenfermeiros.pt/arquivo/... .

Evolution over the centuries is noticeable, both at the level of complexification and the level of dignity of professional practice. The first manual for nurses appeared in 1741, namely, “The Religious Apostille and Art of Nurses”, and was written by a nurse (Frei Santiago). This document shows norms related to the roles of nurses, with two dimensions: the concepts of science at the time, and its experience, showing a perspective of nursing of the late first half of the eighteenth century. Almost 200 years have passed since Florence Nightingale (1860) founded the “New Nursing” with a new paradigm, and turned it into a profession²¹21 Vieira M. Ser enfermeiro. Da compaixão à proficiência. 2ª ed. Lisboa: Universidade Católica Editora; 2009..

The first school for nurses was created in Portugal in 1881, at the Hospitals of the University of Coimbra, and in 1896, another school was established in the city of Porto, at the Santo Antônio General Hospital. In 1899, the International Council of Nurses (ICN) was founded, followed by the American Journal of Nursing in 1900. In 1901, the statutes of the H. Real de São José e Anexos Professional Nursing School were created in Lisbon²²22 Amendoeira J. Profissões e estado: o conhecimento profissional em Enfermagem. In: Lima JA, Pereira HR, organizadores. Políticas públicas, conhecimento profissional: a educação e a Enfermagem em reestruturação. Porto: Pivpsic/Legis Editora; 2008. p. 112-130..

The last century has been beneficial for Nursing in Portugal, with several transformations that once again changed the paradigm and the national picture. Many public and private Nursing Schools (many associated with religious orders) were established. They trained and qualified nurses for professional practice. In 1967, the “systematization of Nursing knowledge began, through the use of research and the identification of an intellectual dimension of Nursing care... the discipline started to emerge as an academic and scientific discipline”²²22 Amendoeira J. Profissões e estado: o conhecimento profissional em Enfermagem. In: Lima JA, Pereira HR, organizadores. Políticas públicas, conhecimento profissional: a educação e a Enfermagem em reestruturação. Porto: Pivpsic/Legis Editora; 2008. p. 112-130., a significant step towards Nursing. The following decade witnessed new achievements. The nurses assumed the positions of school principals (until then held by doctors), with technical and administrative autonomy.

In 1973, the Federation of National Nursing Unions, Portuguese Nurses Association, Catholic Association of Nurses and Health Professionals held the First National Nursing Congress. The congress addressed precursor themes that anticipated the future of nursing and gave rise to drivers that guided the coming years, such as the integration in the National Education System, the need to elaborate the professional statute, and the discussion around the discipline and profession.

The academic recognition of its various levels of education occurs in 1988 with the publication of Decree-Law Nº 480 of 23 December, which regulates the integration of nursing education into the national education system, and was administered in higher schools of Nursing. In Portugal, nursing education has undergone immense changes over the centuries, and with Decree-Law Nº 480/88 of 23 December, it was integrated into higher education. Then, some changes occurred. Amendoeira²³23 Amendoeira J. Ensino de Enfermagem Perspectivas de Desenvolvimento. Pensar Enfermagem [periódico na Internet]. 2009 [acessado 2018 Mar 21]; 13(1):2-12. Disponível em: http://pensarEnfermagem.esel.pt/files/2009_13_1_2-12%282%29.pdf
http://pensarEnfermagem.esel.pt/files/20... summarized such transformations (Figure 4).

Nursing education is structured in three training and research cycles: Pre-Graduate Education – Single-Cycle Bachelor Degree (4 years); Master of Nursing Science (Abel Salazar Biomedical Sciences Institute – ICBAS in 1993/94) and Nursing (at the Catholic University in 1991/92). With Bologna (Decree-Law No. 74/2006, of March 24), it enables the realization of two types of second cycle at the University or in polytechnic education; Ph.D. in Nursing Sciences (at ICBAS – University of Porto, since 2001; at the University of Lisbon in partnership with the Lisbon Higher School of Nursing, since 2004, and the Catholic University, through the Institute of Health Sciences, Ph.D. Nursing Course created in 2004, and adapted to Bologna in 2007. Thirty-seven Portuguese public and private schools have a Nursing course.

At the same time, other relevant events for the profession emerged, such as the REPE approved by Decree-Law N. 161/96. This regulation is a legal instrument applicable in all contexts of nursing activity – public, private, or self-employed. Professional practice should be developed “… Safeguarding the rights and ethical standards specific to Nursing as well as in order to provide citizens in need with quality nursing care” and “clarifies concepts, characterizes nursing care, specifies the competence of legally qualified professionals to provide and defines the responsibility, rights, and duties of these professionals, thus dispelling doubts and preventing misconceptions sometimes raised not only at the level of the various elements of health teams, but also among the general population”¹⁹19 Portugal. Dercreto-Lei nº 161, 4 de setembro de 1996. Regulamento do exercício profissional dos enfermeiros - REPE [documento na Internet]. Diário da República; 1996. [acessado 2018 Mar 21]. Disponível em: https://www.ordemenfermeiros.pt/arquivo/AEnfermagem/Documents/REPE.pdf
https://www.ordemenfermeiros.pt/arquivo/... (p.2).

The constant evolution of society and meeting increasingly demanding levels of health of the population raises the need for access to “nursing care standards of the highest technical, scientific and ethical qualifications”. The OE is created, and its respective Statute is approved by Decree-Law N. 104/98. The OE aims to “advocate for the quality of nursing care provided to the population, as well as the development, regulation, and control of the nursing profession's practice, ensuring compliance with the rules of ethics and professional deontology”²⁴24 Portugal. Ministério da Saúde. Decreto-Lei nº 104, de 21 de abril de 1998. Cria a Ordem dos Enfermeiros e aprova o respectivo Estatuto [documento na Internet]. Diário da República; 1998. [acessado 2018 Mar 21]. Disponível em: https://data.dre.pt/eli/dec-lei/104/1998/04/21/p/dre/pt/html
https://data.dre.pt/eli/dec-lei/104/1998... (p.1741).

As a consequence of the legal-institutional contexts of professional practice, Portuguese nurses may perform a professional activity in public, private, or liberal sector entities, in the context of primary or differentiated health care, in the areas of care, management, and counseling, education, and research. The professional title is granted by the Nursing Association, and only nurses holding this title can exercise this activity.

The International Council of Nurses has adopted May 12 as International Nursing Day. In Portugal, this day is also celebrated, honoring Florence Nightingale, praising nurses and disseminating their contribution to the SNS and health care in general. In 2020, the 200 years of the birth of this icon are marked, and WHO declared next year as the International Year of the Nurse.

Generalist Nurse Competencies

The competencies of the generalist nurses refer to a level of professional performance that shows an effective application of knowledge and skills, which allows them to make clinical judgment and decision-making²⁵25 Portugal. Ordem dos Enfermeiros. Regulamento nº 190, de 6 de março de 2015. Regulamento do perfil de competências do enfermeiro de cuidados gerais [documento na Internet]. Diário da República; 2015. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/67058782
https://dre.pt/application/conteudo/6705... . The competencies' profile has emerged from the consensus on the “ICN Framework of Competencies for the Generalist Nurse”, and since 2003, guides nursing practice. In 2015, the three competency domains - professional, ethical, and legal responsibility; care delivery and management; professional development and 96 competencies have been restructured to meet their certification process (Figure 5).

The exercise of nurses' competencies builds on the following assumptions: (1) the interpersonal relationship between the nurse and the individual client or group – family or community –, with respect for values, beliefs, individual projects and capacities, favoring care in partnership; (2) decision-making based on scientific evidence, clinical judgment is based on the needs of individual or group care and prescribed nursing interventions considering the safety of care and the client, the early detection of real or potential diagnoses seeking resolution or minimization of consequences; (3) humanist, respect for human freedom and dignity and the values of clients, as well as respect for the provisions of the Code of Ethics and professional regulation, which establish good practice²⁵25 Portugal. Ordem dos Enfermeiros. Regulamento nº 190, de 6 de março de 2015. Regulamento do perfil de competências do enfermeiro de cuidados gerais [documento na Internet]. Diário da República; 2015. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/67058782
https://dre.pt/application/conteudo/6705... ^,2626 Queirós PJP, Vidinha TS, Almeida Filho AJ. Self-care: Orem`s theoretical contribution to the nursing discipline and profession. Referência [periódico na Internet]. 2014 [acessado 2019 Ago 01]; IV(3):157-163. Disponível em: https://www.researchgate.net/publication/269398253_Selfcare_Orems_theoretical_contribution_to_the_Nursing_discipline_and_profession
https://www.researchgate.net/publication... .

Portuguese nurses adopt as paradigmatic concept to achieve the goal: (1) health as the subjective and dynamic state of the “individual condition, suffering control, physical well-being and emotional and spiritual comfort”²⁵25 Portugal. Ordem dos Enfermeiros. Regulamento nº 190, de 6 de março de 2015. Regulamento do perfil de competências do enfermeiro de cuidados gerais [documento na Internet]. Diário da República; 2015. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/67058782
https://dre.pt/application/conteudo/6705... (p.8); (2) the individual as a unique and indivisible being in permanent interrelationship with the environment and in an intentional or unintentional process, seeks balance, harmony, well-being and the realization of his health project; (3) environment as the space where one is born, develops and dies; the subject has a conditioning, inhibiting or facilitating factor of lifestyles and consequently of health and; (4) nursing care facilitated by the therapeutic nurse-client relationship focused on the individual health project throughout the life cycle, and the family as a target of the care process and a partner in enhancing health promotion.

They include two types of nursing interventions: interdependent, initiated by other health professionals, and autonomous by nurses, who are responsible for prescribing and implementing nursing actions²⁵25 Portugal. Ordem dos Enfermeiros. Regulamento nº 190, de 6 de março de 2015. Regulamento do perfil de competências do enfermeiro de cuidados gerais [documento na Internet]. Diário da República; 2015. [acessado 2018 Mar 21]. Disponível em: https://dre.pt/application/conteudo/67058782
https://dre.pt/application/conteudo/6705... .

Specialist Nurse Competencies

The Specialist Nurse's Common Competencies Regulation was first published under N. 122 in 2011, republished with amendments in 2019 (Regulation N. 140). The regulation clarifies the different concepts of competencies (common, specific and additional, among others), as well as the different areas of common competencies of the specialist nurse: professional, ethical and legal responsibilities (present during their interventions); continuous quality improvement (streamlines and promotes institutional strategies at the level of clinical governance); care management (organizes and establishes networks and partnerships in the nursing and multi-professional team); development of professional learning (ability to develop self-knowledge, assertiveness in therapeutic and multi-professional relationships in all contexts)”²⁷27 Portugal. Ordem dos Enfermeiros. Regulamento nº 140, de 18 de janeiro de 2019. Regulamento das Competências Comuns do Enfermeiro Especialista [documento na Internet]. Diário da República; 2019. [acessado 2019 Ago 01]. Disponível em: https://dre.pt/home/-/dre/119236195/details/maximized
https://dre.pt/home/-/dre/119236195/deta... .

The specific competencies of different Nursing specialties recognized by the OE for the title of specialist nurse are regulated. The OE still recognizes the following Nursing specialties: Maternal and Obstetric Health (Regulation N. 321/2019); Child and Pediatric Health (Regulation N. 422/2018); Mental and Psychiatric Health (Regulation N. 515/2018); Rehabilitation (Regulation N. 322/2019); Medical-Surgical (EMC-Regulation N. 429/2018) subdivided into EMC to People in Palliative Situation, People in Critical Situation, EMC to People in Perioperative Situation, EMC to People in Chronic Situation; Community Nursing (Regulation N. 428/2018), subdivided into Community Health Nursing and Public Health in the Family Health Nursing area.

Regulation N. 555/2017 (Regulation of Individual Certification of Skills) was published in this context, which certifies the “professional experience and nurse training processes as a whole, in the different fields of intervention, which are intended to be certified, in order to allow the subsequent inclusion in a situation of professional added value”²⁸28 Portugal. Ordem dos Enfermeiros. Regulamento nº 555, de 20 de setembro de 2017. Regulamento de certificação individual de competências [documento na Internet]. Diário da República; 2017. [acessado 2019 Ago 01]. Disponível em: https://dre.pt/home/-/dre/108315074/details/maximized
https://dre.pt/home/-/dre/108315074/deta... (p.23633).

Thus, nurses may apply for the title of Advanced Competency in: Management, Clinical Supervision, Psychotherapy; Stomatherapy, or Differentiated Competency in: Clinical Supervision, Occupational Nursing, Out-of-Hospital Emergency, Stomatherapy, as per the “set of knowledge, skills and attitudes, in the various intervention domains, directed to attest to training, experience or qualification of the nurse in a differentiated, advanced or specialized area, as well as the verification of other conditions required for the practice of nursing”²⁸28 Portugal. Ordem dos Enfermeiros. Regulamento nº 555, de 20 de setembro de 2017. Regulamento de certificação individual de competências [documento na Internet]. Diário da República; 2017. [acessado 2019 Ago 01]. Disponível em: https://dre.pt/home/-/dre/108315074/details/maximized
https://dre.pt/home/-/dre/108315074/deta... (p.23633). Likewise, the OE has published the different competency regulations in these areas as guidance for training and recognition of advanced competencies in the case of specialist nurses and differentiated for general care nurses.

In Portugal, Nursing has a long track of achievements and evolution following the scientific and technological development, with the recognized self-regulation capacity and in the National Classification of Professions, (2008) and is classified as “Specialists of Intellectual and Scientific Professions”. It is an autonomous profession as advocated by the Basic Law of the Educational System for University Education (Law N. 49/2005 of August 30), which in Article 11 says “a technical training that enables the exercise of professional and cultural activities, and fosters the development of design, innovation, and critical analysis skills”²⁹29 Portugal. Assembleia da República. Lei nº 49, de 30 de agosto de 2005. Segunda alteração à Lei de Bases do Sistema Educativo e primeira alteração à Lei de Bases do Financiamento do Ensino Superior [documento na Internet]. Diário da República; 2005. Disponível em: https://data.dre.pt/eli/lei/49/2005/08/30/p/dre/pt/html
https://data.dre.pt/eli/lei/49/2005/08/3... (p.5122). Nursing undergraduate training can only take place in the context of higher education in the polytechnic education subsystem, while masters degrees can be offered in this system and the university subsystem, leaving the doctorate in nursing exclusively in this last subsystem²⁹29 Portugal. Assembleia da República. Lei nº 49, de 30 de agosto de 2005. Segunda alteração à Lei de Bases do Sistema Educativo e primeira alteração à Lei de Bases do Financiamento do Ensino Superior [documento na Internet]. Diário da República; 2005. Disponível em: https://data.dre.pt/eli/lei/49/2005/08/30/p/dre/pt/html
https://data.dre.pt/eli/lei/49/2005/08/3... .

The organization of nursing care focuses on the efficiency and effectiveness of care provided. It is essential to have a framework of reference and a quality system for professional practice and records that incorporate the systematization of information implicit to the nursing process; safe allocation of care and working methodologies; a policy of continuing education and evaluation of nurses' satisfaction according to the quality of professional practice.

Nurses had and have a stake in the quality of life of citizens and the Portuguese health system. Given the constant evolution and influence of new technologies in health care and the emerging challenges, the following reflection emerges: What will be the role of nurses in future generations?

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