Nurse‒physician interprofessional collaboration in the context of expanding nursing practice in primary health care: A comparative qualitative study of Brazil and Germany

Challenges associated with the epidemiological transition from acute to chronic diseases, the aging population, multimorbidity and a shortage of health professionals are faced by health systems worldwide [1, 2]. Complex health needs can be effectively met by strengthening primary health care (PHC) with the goal of providing accessible and comprehensive health care close to communities and throughout the lifespan of individuals. PHC has proven to be capable of meeting most of the population’s health needs [3, 4]. Nurses contribute to PHC by playing a variety of roles with various functions within the framework of PHC models in different countries [5‐7]. In the field of PHC, interprofessional collaboration (IPC) is considered a prerequisite for comprehensive, high-quality care [8, 9].

IPC is defined in terms of integrative cooperation among different health professionals, in which context complementary competencies are combined to deliver the highest quality of care [2, 10]. D’Amour et al. [10] define collaboration through the underlying concepts of sharing, partnership, power, interdependency and process. They refer to IPC as a common space and interdependent relation, where different professionals are challenged to overcome their disciplinary boundaries [10]. Rather than mere plurality or juxtaposition, IPC demands more flexibility in sharing professional responsibilities in a complex system [10]. Interprofessional collaboration is fundamental to all health care settings and particularly important for PHC. According to the Alma-Ata Declaration, PHC has a central role in health systems, with multiple integrative functions [3]. IPC is necessary for PHC to offer promotive, preventive, curative and rehabilitative services because it should integrate all sectors and aspects of national and community development related to health [3]. Notably, PHC relies on a diversity of professionals, including physicians, nurses and others, “suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community” (p.5) [3]. Recent research has shown that interprofessional collaboration in PHC can enhance its effectiveness, leading to better outcomes in terms of medication management and the care process as well as increasing patient satisfaction; evidence has shown that preexisting and well-defined models of IPC have more benefits [11, 12].

Interprofessional collaboration has been identified as a major driver of innovation in PHC [13]. Whereas PHC provision is still physician-centered in many countries, collaboration with other health professionals, particularly nurses, has intensified, thereby increasing the possibility of new arrangements for patient-centered care and practice [14]. However, in his classical essay ‘the doctor‒nurse game’, Leonard Stein [15] described the notion of subordinated nursing practice. He focused on an interaction in which male doctors are the powerholders who make decisions regarding the care to be provided, while acquiescent female nurses contribute their knowledge regarding patients by covertly guiding physicians to provide effective care. McInnes and colleagues [16], in their review of the facilitators and barriers that impact collaboration and teamwork between general practitioners (GPs) and nurses, concluded that nurses in general practice still often do not participate in the processes of goal setting or decision-making. This exclusion of nurses has been criticized as ineffective [14]. Consequently, previous researchers have called for the promotion of horizontal relationships between these two professions [14, 17].

Horizontal professional relationships are based on the values associated with interprofessional collaboration, i.e., trust, mutual respect, equality, and understanding the other party’s role in the care process [10, 17]. However, the ability of physicians and nurses to develop an understanding of the other profession is hindered if the cooperation between these two parties is episodic, relies on referrals and is characterized by sporadic meetings between these two types of professionals [8, 18].

To address chronic conditions and meet long-term care needs, several countries have increased their efforts to expand nurses’ contributions to PHC [19, 20]. Strengthening the nursing profession has been recognized as a suitable strategy for increasing the effectiveness of approaches to PHC [21, 22]. In addition, some scholars have argued that increasing nurses’ engagement in PHC can help address the shortage of general practitioners, thereby decreasing costs and improving accessibility [23, 24]. Moreover, this strategy can promote progress toward more horizontal relationships between nurses and physicians. The expansion of nurses’ roles is closely related to efforts to implement advanced practice nursing (APN). According to the International Council of Nurses (ICN), advanced practice nurses (APNs) are nurses, such as nurse practitioners and clinical nurse specialists, who have specialized knowledge and typically possess a master’s degree; these nurses play an expanded role in their specific context of practice [25]. In particular, APNs make advanced clinical decisions [25, 26]. In PHC, the actual tasks and responsibilities of APNs vary depending on the country and context in which they work [20]. There are countries, such as the United Kingdom and New Zealand, where APNs are more widespread and assume a broad range of tasks, including authorization for prescriptive tasks [26]. In other countries, including Brazil and Germany, the definition of an APN has not yet been legally established; consequently, protected APN role titles such as nurse practitioners have not yet been established.

One task involved in the implementation of APN is reviewing the distribution of tasks according to the competencies of the relevant health professionals [27, 28]. Task shifting from physicians to other health professionals, including nurses, has been supported with the aim of distributing workload among professionals more evenly, thereby increasing service capacity and reducing health care costs [27, 29]. However, in addition to these promising cost benefits, the process of expanding nurses’ tasks in PHC through, for example, APN aims to enrich PHC services, e.g., by implementing models of care on the basis of chronic disease management [6, 21, 30].

The expansion of nurses’ roles and functions in PHC entails certain changes for all the professions involved, particularly with respect to nurses’ collaboration with physicians. Consequently, this process should be analyzed in terms of its intersections with and meanings for the collaboration of nurses and physicians. In this study, we focus on two countries: Brazil and Germany. Neither country has yet implemented an APN, but its potential to improve access to and quality of PHC has been discussed. On the other hand, Brazil and Germany differ greatly in terms of the manners in which they provide PHC. In Brazil, multiprofessional PHC teams are the standard model of care, a situation that involves task sharing and collaboration between nurses and physicians [31, 32]; in contrast, in Germany, PHC is basically provided by GPs with only marginal integration of nurses [19] and a weak collaboration culture [33].

These similarities and differences between these two countries make it interesting to perform a comparative analysis of nurse‒physician collaboration in the context of the expansion of nursing practice. Comparing these two nations can improve our understanding of how contexts might hinder or promote interprofessional collaboration in potential expansions of nursing practice. In addition, such research can deepen our understanding of the movements toward interprofessional collaboration that the expansion of nursing practice in PHC has promoted in different countries. From the perspective of comparative health systems research, “thinking outside the box” is highly relevant and offers a wide range of suggestions and potential ways of optimizing health systems [34]. Accordingly, this study aims to inform future research and policy regarding how interprofessional collaboration can be shaped by the expansion of nursing practices.

In the focus groups, stakeholders and practitioners discussed the current and future prospects of interprofessional collaboration among nurses and physicians in response to the expansion of nursing practice in PHC, particularly through APN. The study revealed various commonalities and differences in the perspectives of participants from Brazil and Germany.

Regarding their assessment of current forms of collaboration, as shown by the first three themes in the analysis, participants in both countries claimed that collaboration between GPs and nurses is required to meet the complex health needs of the population more effectively, a claim that has been reflected in the literature [8]. Internationally, in PHC, nurses’ participation in health work is characterized by a mix of skills [2, 19]. In both Brazil and Germany, the nurses in the focus groups emphasized their contributions to PHC on the basis of their unique insights into patients’ lives. This point refers to the professional self-concept of nursing as a caring profession, namely, a type of care that is oriented toward patients’ lifeworlds and rooted in their experiences [6]. In this study, in the Brazilian context, the nurses emphasized a social and community-based approach to care, whereas in Germany, a home-based, individual and family-based approach was highly valued as an important contribution of nursing to high-quality PHC. The scope of the nurses’ approach in these two countries is in line with the PHC model employed in their respective contexts, e.g., the community-oriented design of PHC in Brazil, in contrast to the home care model used for nursing in Germany. Nurses’ contributions are particularly important in the context of medicalization, in which increasing numbers of life circumstances correspond to diagnoses and thus lead to the prescription of drugs with the goal of eliminating or mitigating their symptoms [56]. Strengthening PHC from the nurses’ perspective offers the opportunity to ensure that care is not focused on medicalization.

The prospects for future collaboration, especially for the stakeholders who participated in this study, focused on expanding the contributions of nurses to PHC as a means of optimizing health work. A report issued by the Organization for Economic Co-operation and Development (OECD) [4] highlights the excessive and unnecessary concentration of physicians’ responsibility for various tasks in PHC. The involvement of nurses in primary care could thus help relevant actors respond to problems of access due to the difficulty of attracting and retaining physicians in PHC—an issue that, as this study revealed, was more strongly associated with Brazil—and to problems pertaining to work overload among physicians—an issue that was more pronounced in the German context. This situation connects the idea of involving nurses with the goal of addressing physician shortages or mitigating physicians’ excessive workload [57, 58]. However, these arguments are still physician-centric. Instead of involving nurses in collaboration because of their own professional identity, they are actually viewed as convenient and secondary resources to physicians. In this sense, if sufficient physicians were available, these reasons for nurses to collaborate would not apply. Such approaches to the assignment of new tasks and roles to nurses in PHC contradict the idea of exploiting the potential of interprofessional collaboration by, e.g., sharing knowledge and complementary skills [2].

Our study revealed that current forms of collaboration between physicians and nurses in PHC centers in Brazil and Germany are shaped by the predominance of physicians in practical care as well as in health politics. Practitioners in Brazil and Germany have reported that medical associations in their countries impose obstacles to the expansion of nursing practices and the enhancement of interprofessional collaboration with nurses in an attempt to maintain a labor market reserve. Medical power in the political sphere is related to the monopoly of care provision, which guarantees an almost exclusive mandate to physicians regarding diagnoses and prescriptions [59]. In Brazil, this discussion is expressed, for example, in the debate regarding the Medical Act Law [60], and in Germany, it is expressed in the so-called reserved tasks (“Vorbehaltstätigkeiten”) [61]. Kroezen et al. [62] reported that physicians’ jurisdictional control over prescriptions is a common issue worldwide, thus causing nurses to occupy a subordinate position regarding prescriptions in most Western European and Anglo-Saxon countries where they are authorized to perform such tasks.

The power imbalance and hierarchical relationships between physicians and nurses have been recognized as problems that condition the possibility of interprofessional collaboration. However, the approach to PHC, the organization of the health work process and even the sociohistorical structures of each country lead to different arrangements for collaboration. Our research revealed that “the doctor‒nurse game” [15] has different features depending on the context in which it occurs. In our study, a higher level of subordination was evident in Germany, whereas a certain degree of paternalism was observed in Brazil. The study highlighted the fact that even when a team-based PHC model is in place, as in the Brazilian health system, the subordination of nurses can nevertheless occur, albeit in a more covert form. A literature review that included studies from Europe, Oceania and North America also concluded that hierarchical relationships between physicians and nurses persist within teams [16].

This consistently imbalanced power relationship is not related only to professional labor markets. Medical hegemony is ethically supported by the knowledge paradigm that establishes the concepts and competences used to provide health care. The liability assigned to physicians is justified by the dominance of a biomedical paradigm that focuses on pathologies and diagnostic classifications based on medical science [56, 59]. The process of prescription has been disputed by the nursing and medical professions on the basis of knowledge claims aimed at obtaining and securing jurisdictional control, respectively [63]. Such disputes could be observed in the prospects for interprofessional collaboration in both Brazil and Germany when the focus group participants contemplated the development of interprofessional collaboration on the basis of the expansion of nursing practice in PHC. Two models of collaboration were mentioned: one model was based on the complementarity between nursing and medicine and supported increasing the autonomy of nurses in the context of an expanded role in PHC, whereas the other model involved the preservation of the hierarchy between these professions, in which context the reserved medical authority would be responsible for delegating tasks pertaining to the expansion of nursing practice. These results correspond to those reported by Kroezen et al. [63], who highlighted similar opportunities and obstacles regarding the expansion of nursing practice in the Netherlands, which was associated with the knowledge claims made by the nursing and medical professions. As a foundation for collaboration, the model of autonomy rather than delegation involves attributing the ability to make decisions, i.e., to prescribe medication, to professionals other than physicians, which entails the abandonment of exclusivity regarding an extremely valuable instrument in the contemporary knowledge domain, namely, at a time when many life events are medicalized [56]. However, it is also necessary to consider a model of care that is based on a paradigm that ranges beyond prescriptive logic to value relational practices and participatory health promotion, given that care is determined by a health–disease process that encompasses more than biological phenomena. In this sense, all professionals, including physicians, must review their roles and identities in a way that is consistent with a conceptual framework appropriate to the complexity of health care needs.

Our findings suggest a relatively favorable but also cautious stance on the implementation of APN and its implications for interprofessional collaboration in PHC in both Brazil and Germany. Notably, the participants’ understanding of APN varied significantly. These variations were examined in greater detail in the study of the enablers and barriers of APN implementation by Bula et al. (in review). However, the focus group participants expressed concerns about interprofessional collaboration with the expansion of nursing practices. The unanimous endorsement of a collaboration model based on the complementarity of physicians and nurses by the participants from Brazil and, in contrast, the diverging opinions reported by the participants from Germany regarding the benefits of complementarity vs. delegation as a modi operandi in physician‒nurse collaboration can be related to the development of nursing in each country. Established university training, protocols/guidelines for autonomous decision-making practices and representations of councils characterize the nursing profession more strongly in Brazil than in Germany [46, 53], which offers better opportunities to expand and strengthen nursing practices in PHC by taking collaboration with physicians into account in an interprofessional rather than multiprofessional way. The rearrangement of responsibilities in PHC was generally identified with task sharing in Brazil, whereas in Germany, it was identified with task transfer. This difference is related to the imprecision of the notion of task-shifting, which is a common expression in the literature, especially that of APN, but which is associated with the notion of transferring or delegating tasks; in contrast, task-sharing has a more explicit meaning that is of greater importance for interprofessional collaboration [28]. However, in both Brazil and Germany, the participants were unanimously opposed to the idea of using nurses as substitutes for physicians, either because doing so could render the nurse’s identity unclear or because it could lead to a situation in which nurses compete with physicians. In the literature, the substitution of physicians by nurses has been widely evaluated, and studies focused on health care outcomes have demonstrated at least similar results regarding the provision of care by both professionals in PHC [64, 65]. In fact, You et al. [66] reported that nurses’ contributions to health indicators can be increased if they are given more autonomy and equality with physicians. Our study reinforces the claim that the aim of expanding nurses’ practice is to strengthen their collaboration by providing them with more autonomy rather than substitution since interprofessional collaboration presupposes that care is provided on the basis of the relationships among different professionals who are characterized by mutual and horizontal ties [2, 10].

In response to contemporary health needs and new care demands, the importance of nurses’ participation in health care, especially in PHC, has increased not only in Brazil and Germany but also in other countries [6, 19]. However, the different challenges faced in this context entail that nurses and physicians can more clearly adopt certain strategic positions depending on the context, e.g., when physicians seek to maintain their centrality in the care process. The prospects for future collaboration varied among the participants in our study because of their different starting points in terms of health system organization and approaches to PHC. These results suggest that collaboration between nurses and physicians is viewed as more interprofessional in Brazil than in Germany. This situation is related to the teamwork experience and the sharing of values for holistic care in PHC in the context of Brazil’s Unified Health System (SUS), especially regarding the Family Health Strategy [67]. In the German health system, on the other hand, intense fragmentation, liberal practice associated with social insurance funding and physician-centered PHC [68] seem to be barriers to attempting to consider the integration of nurses in interprofessional terms rather than identifying it as multiprofessional work. This finding is consistent with Schmid’s [69] observations regarding current financing policies in Germany, which pose challenges for new approaches in PHC due to regulatory structures that largely focus on physicians.

In other words, the different modes of care delivery impact collaboration opportunities between nurses and physicians. The results show that nurses with university training from Brazilian teams in PHC centers provide a consistent framework for interprofessional collaboration between physicians and nurses. Compared with Brazil, in Germany, the findings indicate how the structure of PHC, with its established system of predominantly private GP practices on the one hand and private home care services on the other hand, reflects not only collaboration between physicians and nurses as professionals but also, necessarily, collaboration between these two types of organizations. The chances and obstacles for interprofessional collaboration in general and in the context of the expansion of nursing practice must be reflected against the background of different PHC contexts. The results of our study indicate that nursing professionals in home care services could contribute more strongly to comprehensive PHC in Germany in the future; however, the tasks of nurses in home care services remain limited, as they exclusively provide treatment care (such as administering medication and changing bandages) under the guidance of GPs, in addition to basic personal care and support in domestic care (§ 37, Social Code Book V). The well-established network of home care services in Germany, however, presents significant opportunities for enhancing home-based care for chronically ill individuals, incorporating not only treatment but also promotion, prevention, and rehabilitation services, all of which can be supported by nursing professionals, thereby providing a level of comprehensiveness in PHC that cannot be solely achieved by GPs. The perspective of German PHC provides the first valuable insights into the challenges of integrating advanced nursing contributions into more traditional, physician-centered PHC systems. Until now, medical assistants, and increasingly physician assistants, have been prevalent in GP practices. The roles of physician assistants and medical assistants with additional qualifications have been debated as possible solutions for addressing ongoing shortages in PHC, especially in structurally underserved areas, particularly by younger GPs [70, 71]. This discussion was also partially reflected in our focus groups, where the participating nurses, however, noted that the presence of these assistant roles sometimes posed a barrier to nurses’ effective collaboration with physicians. However, similar to other recent studies (e.g., [72]), physicians demonstrated a willingness to collaborate more closely with nurses to strengthen PHC. In this context, physician representatives showed a positive attitude toward the idea of nurses taking on expanded roles alongside physician assistants and medical assistants. The new Nursing Education Strengthening Act [73], effective in January 2025, incorporates advanced clinical competencies into higher education nursing curricula, focusing on diabetes management, chronic wound care, and dementia. In future studies, the prospects of nurse‒physician collaboration in this changing environment should be investigated in greater detail.

Our study has implications for the development of political conditions and professional education, as they are important prerequisites for the intensification of interprofessional collaboration during the expansion of nursing practice. As a corollary to the results of this research, some of the relevant political conditions entail ethical and legal recognition of the competence of nurses in making clinical decisions without depending on physicians, as other studies have indicated [16, 62]. It is necessary to reach agreements with key players at the political level, such as medical associations and health insurers. A consensus within nursing regarding the development of new forms of collaboration is another such political condition. A relevant prerequisite is professional education, especially with respect to nurses’ broader practice and the joint qualifications of physicians and nurses. These prerequisites are similar to strategies that have been outlined by the World Health Organization since 2010 [2], which focus on the use of political-institutional measures and interprofessional education to implement interprofessional care in health systems.

This article reports the opinions of stakeholders and practitioners (specifically nurses and physicians) regarding nurse‒physician collaboration in PHC in Brazil and Germany. Few studies have addressed this topic by focusing on attempts to strengthen nursing practices or from an international perspective. While Brazil is an important representative of the Global South and features a national health system and a team-based approach to PHC, Germany is a prominent country in the Global North and features a social health insurance system and an approach to PHC that focuses on general practitioners. These differences, especially in relation to the PHC models implemented in these two countries, determine the appropriate methods of collaboration and future projections regarding interprofessionality between nurses and physicians. Nevertheless, Brazil and Germany seem to be in line with international trends toward strengthening the nursing profession in health work, which must become increasingly collaborative to address contemporary needs.

This paper offers evidence regarding the possibilities associated with changes in the relationship between nurses and physicians. The research highlights the openness exhibited by both nurses and physicians with respect to the intensified integration of nurses into PHC work, especially with respect to decision-making. This process is accompanied by the development of broader concepts pertaining to more patient-centered and comprehensive care. In this sense, beyond the prescription of medications, protocols, and professional jurisdictions, interprofessional collaboration should aim at a counterhegemonic model of care that is more effective and humanistic than the current model, which involves unequal health relationships. To be coherent, such a model must be based on professional autonomy and mutuality rather than simply the replacement of physicians with nurses. Real consensus must be reached regarding notions of collaboration that involve complementarity and delegation, autonomy and authority, task-sharing and task-shifting, and multiprofessionality and interprofessionality. In particular, it is necessary to consider the development of new identities of each profession in the context of a model of care that is suited to the demands of the 21st century.