Becoming a specialist: Portuguese nurses’ expectations after completing the specialization program

Background: The Specialization Program in Medical-Surgical Nursing is a postgraduate program that confers the title of specialist, which is recognized by the Portuguese Order of Nurses. Objective: To analyze specialist nurses’ professional expectations after completing the Specialization Program in Medical-Surgical Nursing in Portugal. Methodology: A qualitative study was conducted using semi-structured interviews. The nonprobability convenience sample consisted of 10 specialist nurses. The interviews were transcribed and analyzed according to Laurence Bardin’s content analysis technique. Results: No changes were found in the professional career after the program. The program improved nurses’ knowledge and practice and, consequently, their professional competence. Conclusion: Despite the lack of change in their careers, nurses considered that the program improved their competence in delivering care in their area of specialization.


Introduction
The main purpose of specialization programs is to develop professionals' skills in a specific area of intervention in primary and/or differentiated care. The acquisition of specific professional skills aims to meet the health care needs of the population and facilitate the entry into the job market. It covers issues of daily practice, empowering nurses to intervene using evidence-based approaches focused on delivering care to patients/families in specific health care settings (Paz & Dagmar, 2011). A necessity of Portuguese society, specialized nursing training allows many nurses to acquire the necessary qualifications, making them more capable of providing specialized care and contributing to the development of nursing education. This study analyzes the consistency between specialist nurses' training and nursing care quality, thus facilitating the redefinition of the curriculum based on the outcomes in professional practice. Therefore, the study also reflects on the impact of the Specialization Program in Medical-Surgical Nursing (Curso de Especialização em Enfermagem Médico-Cirúrgica, CEEMC) of a Nursing School on nurses' professional practice. Thus, the purpose of this study is to analyze the specialist nurses' professional expectations after completing a CEEMC in Portugal.

Background
In 1981, the Decree-Law no. 305/81 of 12 November on the career of the nursing profession established, for the first time in Portugal, a single career for the profession, regardless of the area or setting of professional practice (Decreto-Lei nº 305/81, de 12 novembro). With the integration of nursing education into the Portuguese education system, this Decree-Law was amended by Decree-Law no. 437/91 of 8 November, which included nurses' evaluation by nurses and the responsibilities for the different categories (Decreto-Lei nº 437/91, de 8 novembro). It should be noted that, in this Decree, the qualification of specialist nurse (enfermeiro-especialista) is essential to be promoted to the category of head nurse (enfermeiro-chefe). In addition, the nursing specialization program continued to be a pre-requisite to anyone who wanted to attend the Service Administration Program (Curso de Administração de Serviços) in order to be eligible for administration positions (Carmo, 1994). This Decree also reinforced the need to develop post-basic nursing education in Portugal. In this respect, the three nursing schools in Lisbon, Coimbra, and Porto offer post-basic education since 1983, namely specialization nursing programs (Amendoeira, 2009). The CEEMC was created by the decree published in 1985 (Nunes, 2007). Until then, Portugal had no specialist nurses in medical-surgical nursing. According to Pacheco, Oliva, and Lopes (2005), health organizations were then asked to refer nurses to integrate the faculty until the nursing schools were able to create a qualified team for post-basic nursing education. According to these authors, the CEEMC was designed to train specialist nurses in medical-surgical nursing with an emphasis on critically-ill patients, health services management, education, and participation in research. In 1988, nursing education was integrated into the Portuguese education system. The subsequent changes in nursing programs, namely the creation of specialized nursing programs, contributed to the development of nursing as a discipline with scientific and pedagogical autonomy and, ultimately, to the social recognition of the profession (Pedrosa, 2001). In 1994, the Specialized Higher Education Nursing Programs (Cursos de Estudos Superiores Especializados em Enfermagem) were created and regulated by Order no. 239/94 of 16 April (Michel, Vieira, & Gutiérrez, 1992). Later, in 1996, the Regulation of Nurses' Professional Practice (Regulamento do Exercício Profissional dos Enfermeiros, REPE) was published. This document clarified nursing-related concepts, nurses' autonomous and interdependent functions, and the professionals' rights (Carrijo, 2006;Carvalho, 2010). Finally, in 1998, the Portuguese Order of Nurses (Ordem dos Enfermeiros, OE) was created. It laid down the conditions for the consolidation of nurses' autonomy, namely some of their responsibilities: the promotion of nursing care quality; the regulation and control of the nursing profession; and the respect for professional ethics and deontology (Carvalho, 2010). Nurses' professional training is essential given the constant changes in society, which reflect the evolution of science and the development of knowledge and innovative techniques in various professional areas, specifically in the health area. Specialization nursing programs were created to respond to this new reality. The CEEMC is a postgraduate degree that confers the OE-recognized title of specialist to professionals who possess the necessary human ROSANA MARIA DE OLIVEIRA SILVA et al. and technical skills to provide general and specific care in their area of expertise (Ministério da Saúde, 1998). In 2011, the OE defined nurse specialists' common skills in the following domains: professional, ethical, and legal responsibility; quality improvement; care management; and professional learning (OE, 2011). In accordance with Regulation no. 122/2011 of 18 February: Regardless of the area of expertise, all specialist nurses share a set of domains, which are considered common skills -the specialist nurse intervenes using skills applicable to primary, secondary, and tertiary care environments, in all health care delivery settings. The intervention of the specialist nurse also involves the dimensions of client and peer education, guidance, counseling, leadership, as well as the responsibility to decode, disseminate, and conduct relevant research which can contribute to improving nursing practice. (OE, 2011, p. 8648)

Research question
What are specialist nurses' expectations after completing the nursing specialization program?

Methodology
A qualitative exploratory study was conducted as a result of a sandwich Ph.D. program developed in Portugal. A nonprobability convenience sampling technique was used to select a sample of 10 specialist nurses who met the following inclusion criteria: having completed the CEEMC, working in a large teaching hospital between January and February 2012, and accepting to participate in the study by signing the Informed Consent Form. Data were collected using semi-structured interviews based on the following guiding questions: "Please tell me about your personal, social, and professional life trajectory since you've completed the Specialization Program in Medical-Surgical Nursing?"; Why did you decide to attend this specialization program?"; and "To what extent did this specialization program contribute to your professional practice?". Data collection started after the approval of the education and health institutions for the development of the study and the identification and location of the subjects.
Specialist nurses were identified based on the above-mentioned inclusion criteria. Nurses who refused to participate or were not present at the unit during data collection were excluded from the study. Therefore, the nursing service provided information concerning the nurses who had completed a specialization, namely their full name and the hospital units where they worked. Fifteen specialist nurses were identified and located; however, due to several reasons, five could not participate in the study. Ten specialist nurses were interviewed between January and February 2012. Nurses were contacted to explain the purpose and objectives of the study, emphasizing the importance of their participation. Some nurses agreed to be immediately interviewed, while others scheduled a specific time and place to be interviewed later. The objectives, the nature, and the potential repercussions of the study were explained to the nurses before the interview. They were ensured anonymity, asked permission for digital recording of the interviews, and asked to sign the Informed Consent Form. The interviews took place at the hospital facilities in a location chosen by the interviewees, which was near the unit where the nurses worked so as to avoid any interruptions. In this study, the analysis process was continuous, dynamic, methodical, understandable, reflective, and flexible to make better use of the interviews. In total, the interviews lasted 42 hours and 30 minutes. They were transcribed using the professional software, Express Scribe 5.20. In order to safeguard their identity, participants were assigned the letter P for participant and numbered from 1 to 10. Subsequently, a thematic analysis was performed following three steps: pre-analysis; material exploration; and results treatment, inference, and interpretation (Bardin, 2009). In this way, a first reading of the 10 interviews was carried out with the purpose of building the corpus of analysis for this study. Later, in the material exploration phase, the content was extensively analyzed using semantics. Then, the contents were decomposed, itemized, coded, and categorized for analysis and interpretation.

Results
In this study, two categories of analysis emerged from data analysis: No changes in the professional career after completing the specialization program; and Contributions Becoming a specialist: Portuguese nurses' expectations after completing the specialization program of the specialization program to the personal and professional trajectory.

No changes in the professional career after completing the specialization program
In this category, participants reported that there were no changes in their professional career after completing the program because the nursing career is currently stagnant, without changes in roles or open tenders for specialist nurse, as shown by the following accounts: After the specialization, there were not many changes because it's a recent thing . . . There aren't many prospects at this moment because the job market is difficult. In the current economic situation, there aren't many prospects of tenders for specialist nurses. ; January, 2012) Based on these accounts, and in line with the units of register, participants seem to be pragmatic in relation to the lack of impact of the specialization program on their professional career as a result of the economic crisis that Portugal has faced since 2008. Therefore, the lack of career progression after the specializa-tion program justifies the importance of this category.

Contributions of the specialization program to the personal and professional trajectory
In this category, the majority of participants reported that the program had contributed to expand their knowledge, change their way of looking at the patients, and, consequently, improve their professional competence. This is illustrated by the following accounts: "Now I pay more attention to other people, I feel the need to explain things even if they don't ask me. But not in my social life. Everything stayed the same, with my parents, my friends, my colleagues" (P. 4; January, 2012); "The specialization made me see things and face challenges differently. How to deal and overcome them, how to see every opportunity as a challenge rather than an obstacle" (P.8; February, 2012); "Now, of course, the specialization gave me more theoretical knowledge and made me reflect on our practical knowledge during care delivery" (P.9, February, 2012); "Because I'm more aware of certain situations now than before. And I think that we need to be more sensitive, more aware of certain realities than before. I wasn't aware before..." (P.10; February, 2012); . . . Basically, this was an important contribution of the specialization . . . a more comprehensive notion of what is necessary to organize a set of activities. I mean, it's not just about patient care, it's also about learning to effectively manage the whole complexity of patient care. (P.5; January, 2012) The participants also reported that the CEEMC provided them a more critical perspective of their practice and more insights to face the challenges in nursing care delivery. However, they did not perceive any change in their personal and professional life after the program.

Discussion
With regard to the first category, nurses who completed the specialization program mentioned that there is no career progression after becoming a specialist because of the crisis that has affected Europe since 2008, which, among other consequences, led to the stagnation of the nursing career. Health professions are directly interconnect-ed with a capitalist logic and, therefore, to its historical movement, oscillating in certain periods due to a reduction in capital production (Gross Domestic Product), and subsequent job losses and market stagnation (Lanza, Campanucci, & Baldow, 2009). From this perspective, the nursing specialization program does not emerge as a peripheral and separate element, but rather in close connection with the socio-economic context in which society is organized and integrated, as well as with the health sector. It should be noted that Decree-Law no. 305/81 of 12 November restructured the nursing career in the Portuguese system, thus creating the category of specialist nurse and the requirement of this title to progress to a leading position (Decreto-Lei nº 305/81, de 12 novembro). However, this progression depends on the government's decision to open tenders for this position. Upon completing the specialization, nurses are aware of the government's interference in the stagnation of their career. In relation to the second category, the participants were aware of the changes in their way of seeing and performing their role as nurses as a result of the acquisition of new knowledge and skills, thus becoming more confident in their decision-making and ability for a holistic and individualized perspective of patients' needs. In this way, specialist nurses considered that the specialization program was an added value because it allowed them to establish an effectively therapeutic relationship and provide more humanized care towards the individualization of the patient and family (Anderson, Linden, Allen, & Gibbs, 2009). Highly-qualified professionals, aware of their professional practice and possessing critical thinking and problem-solving skills, are expected to play a key role in improving health care quality (Carbogim, Santos, Alves, & Silva, 2010). Knowledge development is essential in nursing practice to efficiently solve health care problems, critically analyze professional practice, and safely intervene based on responsible decision-making (Silva, Cordeiro, Fernandes, Silva, & Teixeira, 2014). The specialization program also allowed nurses to update and improve their knowledge, which had a positive impact on their professional practice by broadening nurses' perspective as a result of their reflection about their practice, based on the assumption that the human being is not fragmented. Furthermore, nursing specialization programs increase the human intellectual capital, improve care quality, promote learning, and lead to changes in all health organizations (Anderson, Hair, & Todero, 2012). However, nurses should master both the practical and the scientific knowledge inherent to their area of professional activity in order to deliver safe, effective, and high-quality care (Carbogim et al., 2010). However, the changes resulting from the nursing specialization have led to an increasingly competitive market, with health care users who are now more demanding and aware of their rights. Consequently, there is the need for a new profile of professionals capable of assuming responsibilities and making decisions to solve increasingly complex situations. Therefore, since specialists' training should meet the needs of the job market, the professional profile requires innovative and relevant ideas, as well as the ability to understand the health care philosophy and establish more effective strategies for solving the health problems of the population (Paz & Dagmar, 2011;Maxwell, 2011). Finally, as a social practice, nursing has integrated the managerial and technological restructuring of the health sector, which has changed nurses' role and work process and, consequently, has given rise to the need for specific qualifications for clinical practice and the acquisition of new skills. The limitations of the study are related to its method since the study was developed with only 10 nurses.

Conclusion
The nursing specialization program contributes to specialist nurses' professional development by improving their knowledge and competence, as well as their critical thinking, problem-solving, and decision-making skills. However, the political and economic scenario worldwide has made the job market more diversified, dynamic, and complex, particularly in the health area. In this context, professionals are expected to have specific skills, be more efficient and effective in care delivery, and be capable of adapting to constant physical, biological, psychological, spiritual, cultural, and environmental changes. The instability of this scenario has been interfering with the nursing job market, leading to unemployment, precariousness, and stagnation in nurses' professional career.
Becoming a specialist: Portuguese nurses' expectations after completing the specialization program In view of the above, further studies should be conducted with larger samples from different areas of expertise to provide a more accurate response to the problem under analysis.