Bielefeld School of Public Health

Project Funding
Germany:

Brazil:
Fundação Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) - Programa Probral

Background

Population aging and the rising prevalence of chronic diseases and challenge health systems and primary health care provision globally. In many countries, expanding the roles of the nursing profession and promoting interprofessional collaboration has been acknowledged as a strategy to strengthen primary health care.

Advanced Practice Nursing (APN) roles in primary health care have been established in many countries. In Brazil, the tasks and responsibilities of primary health care nurses have also been expanded in recent years. In Germany, there are – to a lesser extent – efforts to develop and expand the contribution of nurses in primary health care; in both countries, however, the development of APN in practice is still in its infancies.

Objectives

A team composed of researchers from Germany and Brazil comparatively analyses possibilities and obstacles to expanding nurses’ tasks and responsibilities, APN implementation, and strengthening interprofessional collaboration in primary health care in Brazil and Germany. On this basis, the following objectives are addressed:

1. to identify strengths, possibilities, and obstacles of nursing roles expansion, APN implementation, and as a consequence, new models of interprofessional collaboration in primary health care in Brazil and Germany;
2. to compare the cases of Brazil and Germany considering health systems contexts and primary health care models; and
3. to inform and make recommendations for future research, policies and practices on the implementation of APN as well as models of collaboration in primary health care.

Approach

Funding period I (2022-23):

The following steps were implemented during the first funding period:

• Literature and document analysis
• Focus groups (n=9) with a) nurses and physicians practicing in primary care and b) decision makers from regulatory bodies in Brazil and Germany
• Research-related seminar with Master of Public Health students at Bielefeld University

At the end of the first project phase rich qualitative data was produced and analyzed. Further analyses will be undertaken in the second project phase.

Funding period II (2024-25):

For the second funding period the following steps are planned:

• Associating new cooperating institutions to the network (Universidade Franciscana, Universidade Federal do Rio de Janeiro, Universidade Estadual do Rio de Janeiro)
• In-depth analyses of the data produced in project phase I (Themes: health systems perspectives on nursing; interprofessional collaboration; APN implementation; methodological challenges in international comparative qualitative research)
• Research-related seminar with Master of Public Health students at Bielefeld University
• Associating new doctoral projects to broaden the scope of the research network, in particular on the topic of nurse migration from Brazil to Germany

Publications

Contributions to Journals

• Bula, D., Franco, C.M., Giovanella, L., Toso, B.R.G. de O., Heumann, M., & Hämel, K. (2025). The Implementation of Advanced Practice Nursing in Primary Health Care: A Comparative Qualitative Study of Enablers and Barriers. Journal of Advanced Nursing. https://doi.org/10.1111/jan.70172
• Felix, V.C.H., de Oliveira, D.C.C., Franco, C.M., Rodrigues, R.M., Engstrom, E.M., Giovanella, L., Hämel, K., et al. (2025). Shared care practices between nurses and physicians in primary care. Acta Paulista de Enfermagem, 38, eAPEoo3024i. https://doi.org/10.37689/acta-ape/2025AO003024i
• Franco, C.M., Bula, D., Toso, B.R.G. de O., Giovanella, L., & Hämel, K. (2025). Nurse-physician interprofessional collaboration in the context of expanding nursing practice in primary health care: A comparative qualitative study of Brazil and Germany. BMC Nursing, 24(1), 259. https://doi.org/10.1186/s12912-025-02885-5 
• Heumann, M., Röhnsch, G., Zabaleta‐del‐Olmo, E., Toso, B.R.G. de O., Giovanella, L., & Hämel, K. (2023). Barriers to and enablers of the promotion of patient and family participation in primary healthcare nursing in Brazil, Germany and Spain: A qualitative study. Health Expectations, 26(6). https://doi.org/10.1111/hex.13843
• Veiga, A.C. da, Medeiros, L. da S. de, Backes, D.S., Sousa, F.G.M. de, Hämel, K., Kruel, C.S., & Haeffner, L.S.B. (2023). Interprofessional qualification of prenatal care in the context of primary health care. Ciência & Saúde Coletiva, 28(4), 993-1002. https://doi.org/10.1590/1413-81232023284.14402022en
• Bula, D., Heumann, M., Hämel, K., Toso, B.R.F. de O., Rodrigues, R. M., & Rizzotto, M.L.F. (2022). Advanced practice nursing: Cooperation between Brazil and Germany for exchange and research development [in Portuguese: Enfermagem em prática avançada: Cooperação entre brasil e alemanha para intercambio e desenvolvimento de pesquisa]. Varia Scientia - Ciências da Saúde, 8(1), 10-12. https://doi.org/10.48075/vscs.v8i1.29594

Reports

• Bula, D., Engstrom, E.M., Giovanella, L., Hämel, K., Heumann, M., Felix, V.C.H., Luisi, D.; Rodrigues, R.M.; Rizzotto, M.L.F.; Toso, B.R.G. de O., & Zwergel M. (2024). Health Systems, Primary Health Care and Nursing in Brazil and Germany. Report of the research network “Strengthening Advanced Nursing and Collaboration in Primary Health Care.
  Bielefeld: Universität Bielefeld, Fakultät für Gesundheitswissenschaften. https://doi.org/10.4119/unibi/2988035

Abstracts

• Chaves, D.C.C., Zwergel, M., Heumann, M., Felix, V.C.H., Franco, C.M., Pereira A., Oliveira de Carvalho J., Bula, D., Luisi, D., Nowak, A.C., Giacomini, E., Engstrom, E.M., Rizzotto M.L.F., Rodrigues R.M., Backes D.S., Giovanella L., Toso B.R.C. de O., & Hämel K. (2024). MAXQDA as an instrument for international collaboration in research. MQIC – MAXQDA International Conference - Learn. Discover. Connect. 28 Feb – 01 Mar 2024, Berlin, Germany.
• Bula, D., Heumann, M., Toso, B.R.G. de O., Giovanella, L., Franco, C.M., & Hämel, K. (2023). Promoting and hindering conditions for the implementation of advanced practice nursing in primary care in Germany and Brazil. 22. Deutscher Kongress für Versorgungsforschung (DKVF) Düsseldorf: German Medical Science GMS Publishing House. https://doi.org/10.3205/23DKVF328
• Hämel, K., Franco, C., Bula, D., Pereira, A., Giovanella, L., Heumann, M., Carvalho, J., et al. (2023). Strengthening Advanced Practice Nursing and collaboration in primary health care – A comparative study on the cases of Brazil and Germany. In European Forum for Primary Care (EFPC) (Ed.), Programme Book of the 18th EFPC Conference Barcelona "International humanitarian crises: What is the role of primary care for international social cohesion?" (p. 33).
• Hämel, K., Heumann, M., Toso, B.R.G. de O., Bula, D., Engstrom, E.M., Rizzotto, M., & Giovanella, L. (2023). Strengthening advanced practice nursing and collaboration in PHC in Brazil and Germany. Population Medicine, 5, A1721. https://doi.org/10.18332/popmed/165761
• Toso, B.R.G. de O., Horewicz, V., Bula, D., Heumann, M., Hämel, K., Rodrigues, R.M., Rizzotto, M., Giovanella, L., & Engstrom, E.M. (2023). Implementation of advanced practice nursing in primary health care in Brazil. Population Medicine, 5, A1721. https://doi.org/10.18332/popmed/165343
• Heumann, M., Röhnsch, G., Zabaleta-del-Olmo, E., Toso, B.R.G. de O., Giovanella, L., & Hämel, K. (2022). Participation and chronic illness: Nurses’ perceptions in primary care in Brazil, Germany, and Spain. European Journal of Public Health, 32(Suppl. 3), ckac129.721. https://doi.org/10.1093/eurpub/ckac129.721