Essential health promotion competencies in nursing training: an integrative review

Abstract

Objective:

to analyze the evidence available in the literature on essential health promotion competencies related to Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) project, in nursing training in the Brazilian context.

Methods:

this is an, integrative literature review in the PUBMED, Web of Science, CINAHL, LILACS, BDENF and Scielo Electronic Library databases, with descriptors “Nursing”, “Health Promotion” and keywords “Competencies” and “CompHP”. Articles published since 2011, in Portuguese, English and Spanish were eligible. The guiding question and the searches in the databases occurred from PVO strategy.

Results:

six publications were included, with two thematic categories being established: Development of CompHP Competencies in nursing training; Teaching Health Promotion Competencies. CompHP competencies have been developed during nursing training; however, only three of them regularly: enable change, mediation through partnership and leadership.

Conclusion:

this study expands the understanding of how some processes related to CompHP have been incorporated into nursing training, in addition to addressing their importance for critical and reflective training from the incorporation of essential competencies in the curriculum of undergraduate nursing courses in the Brazilian setting.

Keywords
Professional competence; Health promotion; Professional training; Nurses

Resumo

Objetivo:

Analisar evidências disponíveis na literatura sobre as competências essenciais de promoção da saúde relacionadas ao Projeto, “Desenvolvendo competências e padrões profissionais para a construção da capacidade em promoção da saúde na Europa” (CompHP), na formação do enfermeiro no contexto brasileiro.

Métodos:

Revisão integrativa de literatura nas bases de dados PUBMED, Web of Science , CINAHL, LILACS, BDENF e Biblioteca Eletrônica Scielo, com descritores “Enfermagem”, “Promoção da Saúde” e palavras-chave “Competências” e “CompHP”. Foram elegíveis artigos publicados a partir de 2011, nos idiomas português, inglês e espanhol. A questão norteadora e as buscas nas bases de dados ocorreram a partir da Estratégia PVO.

Resultados:

Seis publicações foram incluídas, sendo estabelecidas duas categorias temáticas: Desenvolvimento de Competências do CompHP na formação do enfermeiro; Ensino das Competências de Promoção da Saúde. As competências do CompHP têm sido desenvolvidas durante a formação do enfermeiro, contudo, apenas três delas com regularidade: Possibilidade de mudança; Parceria e Liderança.

Conclusão:

Este estudo amplia a compreensão sobre como alguns processos relacionados ao CompHP têm sido incorporados à formação de enfermeiros, além de versar sobre sua importância para a formação crítica e reflexiva a partir da incorporação das competências essenciais no currículo de cursos de graduação de enfermagem no cenário brasileiro.

Descritores
Competência profissional; Promoção da Saúde; Capacitacão profissional; Enfermeiros

Resumen

Objetivo:

Analizar las evidencias disponibles en la literatura sobre las competencias esenciales de promoción de la salud relacionadas con el proyecto “Desarrollo de competencias y criterios profesionales en la construcción de capacidades para la promoción de la salud en Europa” (CompHP) en la formación del enfermero en el contexto brasileño.

Métodos:

Revisión integradora de literatura en las bases de datos PUBMED, Web of Science , CINAHL, LILACS, BDENF y Biblioteca Electrónica Scielo, con descriptores “Enfermería”, “Promoción de la salud” y palabras clave “Competencias” y “CompHP”. Los artículos elegibles fueron los publicados a partir de 2011, en portugués, inglés y español. La pregunta orientadora y las búsquedas en las bases de datos se realizaron siguiendo la estrategia PVO.

Resultados:

Se incluyeron seis publicaciones y se establecieron dos categorías temáticas: Desarrollo de competencias del CompHP en la formación del enfermero; Enseñanza de las competencias de promoción de la salud. Las competencias del CompHP fueron desarrolladas durante la formación del enfermero, sin embargo, solo tres de ellas con regularidad: Posibilidad de cambio, Colaboración y Liderazgo.

Conclusión:

Este estudio amplía la comprensión sobre cómo algunos procesos relacionados con el CompHP fueron incorporados a la formación de enfermeros, además de abordar su importancia para la formación crítica y reflexiva a partir de la incorporación de las competencias esenciales en el diseño curricular de carreras de grado de enfermería en el escenario brasileño.

Descriptores
Competencia profissional; Promoción de la salud; Capacitación profesional; Enfermeros

Introduction

Health promotion (HP) is understood as a process of training subjects for health care, seeking autonomy at the individual and collective levels, in order to improve the determinants of the health-disease process and, consequently, quality of life. It emerges in the world in the 1970s, through the Lalonde report, based on an understanding that the care model, focused on the treatment of diseases and rehabilitation, did not correspond to the expanded concept of health.^(1,2)

Since that period, successive conferences promoted by the World Health Organization (WHO) have taken place to debate and agree on public policies that meet a new logic of acting and training in health, in its different fields,⁽²⁾since, without the political commitment in actions and investments to deal with health and equity, without partnership and demand between the different social actors, the health sector will not reach the health levels desired for the population.⁽²⁾

In Brazil, advances were achieved when the Brazilian National Health Promotion Policy (PNHP – Política Nacional de Promoção da Saúde ) started the formulation, implementation and implementation of actions that could (re) build a health care model, which prioritized improving the quality of life of the subjects and the collective action through the expansion and qualification of HP actions in services and in the management of the Unified Health System (SUS - Sistema Único de Saúde ).⁽³⁾

In the health field, there is a concern with specific professional training in HP. In this sense, several initiatives, especially international ones, have contributed to training of human resources in health, with the construction and use of competencies for HP. Countries like Canada, Australia and others on the European continent have stood out in this direction. However, in Latin America, more needs to be done, considering the inclusion of knowledge and skills on HP strategies in the training of health professionals.⁽⁴⁾

In 2009, the International Health Promotion and Education Union started to devise the manual based on the Developing Competencies and Professional Standards for Health Promotion Capacity Building in Europe (CompHP) project. The project contributed to raising Galway’s core competencies to professional standards, proposing an accreditation chart for the practice of HP, with the aim of positively impacting the training and human resources of the European continent.^(4,5)

The essential competencies of the CompHP project are described as “a set of roles expected of health professionals, so that they are able to work efficiently”. Despite being developed for a specific reality, CompHP was built from a wide literature review of existing essential HP competencies and several rounds of consultations with countless specialists, in order to impact a multicultural reality.^(5-7)

The essential competencies for working at HP defined by the project include a set of 68 competency statements, arranged in eleven domains, namely: Enable changes, Advocate for Health, Mediate through Partnership, Communication, Leadership, Assessment, Planning, Implementation, Evaluation and Research. In turn, these competencies must be developed and guided by Ethical Values and Knowledge domains in HP.^(5-8)

In the context of nursing, it is emphasized that the traditional teaching model, even with advances in curricular organization, has not been able to train generalist nurses to work effectively at HP, one of the structuring axes of SUS, in the Brazilian case. Competencies teaching for HP in nursing training should be analyzed, identifying experiments and experiences in this process.⁽⁹⁾Furthermore, the inclusion of HP in curricula, in general, has been related to health education activities in different contexts.⁽⁹⁾

Behind this setting there is a clash of the different perspectives of HP, reflecting the necessary and still low solidity of the intersectoriality in the elaboration of the PNPS, which mentions the importance of establishing partnerships, but, in its initial formulation, the agreement and dialogue with the sectors of society proceeded insufficiently.^(3,10)

On the other hand, there is a consensus established in the literature on the importance of developing an effective and sustainable network of professionals involved with HP competencies.^(4,5,9)Thus, this study aimed to analyze the production of scientific knowledge about HP competencies related to CompHP and relevant to nursing training in Brazil.

Methods

The integrative review was developed following the steps: elaboration of the research question; establishment of inclusion and exclusion criteria; search for primary studies; evaluation of included studies; categorization of studies; interpretation of results; synthesis of the evidenced results.⁽¹¹⁾

PVO (Population/problem, Variables and Outcomes) strategy was used and the guiding question was reached: what is the evidence present in the scientific literature about the development of HP competencies related to CompHP in nursing training? P would be nurses, V training for HP and O the identification of aspects of HP competency related to the project CompHP.⁽¹²⁾

For the selection of articles, searches were conducted in September 2018 in the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), National Library of Medicine (PubMed), Web of Science (WOS), Latin American Literature and Caribbean Health Sciences (LILACS), Nursing Database (BDENF) and Scientific Electronic Library Online (SciELO). In order to choose descriptors and keywords, terms were surveyed using the PVO strategy, and a query was made to the vocabulary proper to the bases involved in the study. After analyzing combinations of controlled descriptors, we opted for using the descriptors nursing, health promotion and the keywords competence, CompHP, in order to expand the results to published articles that, possibly, had not undergone, analysis for indexing the terms. We used the Boolean operators AND and OR and truncations ($ and *). The terms of the descriptors were adopted in trilingual, Portuguese, English and Spanish, on national bases, and we used the crossing (Competence OR Competencies OR CompHP) AND health promotion AND (nursing OR Nurse*).

The search and selection of articles were carried out by two researchers independently. The inclusion criteria were: articles from primary studies published in Portuguese, English and Spanish, which addressed the theme of developing HP competencies analyzed in the light of the CompHP framework; journals indexed in the databases selected between the period 2011 and July 2018, i.e., since the publication of the 1^stCompHP manual - “The Core Competencies Framework for Health Promotion Handbook”, published in 2011.⁽⁸⁾Exclusion criteria were: reviews, theses, monographs, dissertations, editorials, responses to the editor, letters and experience reports. In cases of disagreement between the researchers, a consensus was reached for selection.

Previous filters were carried out, with respect to the period and languages in the chosen databases. From the results of the search strategies in the databases, we generated a file that was imported into the EndNote reference manager and folders were created for each database. Subsequently, duplicate studies were excluded, which did not address the topic after reading the title and abstract, and coming from incompatible documents for inclusion. Thus, 17 articles were selected for reading in full and six included in this review. The selection of studies followed the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) method, with adaptation of the flowchart ( Figure 1 ).⁽¹³⁾

Figure 1
Flowchart of the search for primary studies in the selected databases⁽¹³⁾

To extract the information and analyze the selected articles, a synthesis matrix was created, including items such as study identification, language, country of origin, study design, sample size, analysis method, results found, conclusions/recommendations. After data extraction, data analysis of the fragments of results/conclusions of each study was carried out, with reading and rereading of the extracted data, gathering data and categorizing the theme and producing a final report, articulating the objective of the study and the data found. The classification of the level of evidence followed: Level I, from systematic review or meta-analysis; Level II, randomized controlled clinical trial; Level III, controlled clinical trial without randomization; Level IV, cohort or case-control studies; Level V, originating from a systematic review of descriptive or qualitative studies; Level VI, descriptive or qualitative study; Level VII, resulting from the opinion of authorities and/or expert committee reports.⁽¹⁴⁾

Results

The six articles included in this review were developed in Brazil and published in the last four years. As for the researchers, five studies had nurses as their main authors, and one article was produced by physical therapists. There was a predominance of institutions in southeastern Minas Gerais, a greater number of public than private institutions, but four studies were identified in northeastern, one in southern and one in center-western. The characterization and synthesis of the main findings in the articles found are presented in Chart 1 .

Chart 1
Syntheses of studies included in the integrative review

Authorship	Objectives	Year	Country	Journal/field/database	Design/level of evidence	Main results
Silva KL, Barcelos BJ, France BD, Araújo FL, Magalhães IT, Ledo MM.(15)	Analyzing the teaching of competencies for HP in nursing training, identifying experiments and experiences in this process.	2018	Brazil	Interface comunicação, saúde e educação / Education and Research in Public and Environmental Health Education/SciELO	Qualitative study/ VI	From the study of CompHP’s essential competencies, it became evident that competencies are temporarily taught in contact with reality, through experimentation and experience. The results indicate that the teaching of competencies for HP occurs at different times and spaces of nursing training; however, the experimentation of HP is determined by a specific place and time in the training. The social practice in the field of competency formation is still marked by the traditional model of teaching and the conception of HP. HP teaching and its competencies occurs in a general way; however, it is not specified which domains must be reached.
Netto, L Silva, KL.(16)	Analyzing the insertion of reflective professional practice as a strategy for the development of competencies for HP in nursing training.	2018	Brazil	Revista da Escola de Enfermagem da USP / Nursing SciELO LILACS CINAHL	Qualitative study/ VI	The most favorable contexts for reflective practice for the development of competencies for HP are those that include teaching-service-community integration, professor-student interaction and teamwork. The participants’ speeches reveal conceptual inaccuracy regarding HP.
Dias IKR, Teixeira OF, Teodoro IP, Maia ER, Lopes MV, Machado MS.(17)	Verifying the perspectives of professors of an undergraduate nursing course about CompHP domains, and how these are present in their practice.	2018	Brazil	Cogitare Enfermagem - Nursing CINAHL, LILACS	Qualitative study/ VI	CompHP domains could be evidenced in teaching practice. Among the nine domains studied, only four were manifested in professional knowledge. They are: enable change, mediate through partnership, leadership, and assessment. No professor has demonstrated ownership in more than one CompHP domain
Carvalho VL, Oliveira AL, Alves IK, Silva RL, Silva CB.(18)	Assessing the degree of HP competencies among the graduates of courses in the health field.	2017	Brazil	Uma Revista enfermagem UFPE on-line /Health Sciences - Nursing / BDENF	Quantitative Study/ VI	The study used an adapted questionnaire, composed of the set of 11 ComHP competency domains to assess the degree of competencies in HP and points to a development below the desirable, with regard to the competencies necessary to carry out the activities of HP, during the courses undergraduate researched. This fact was noticed when students said they did not recognize such competencies.
Silva KL, Gonçalves GA, Santos SB, Machado MF, Rebouças CB, Silva VM, Ximenes LB.(19)	Recognizing the domains of HP competencies in the training process of adolescents carried out by nursing students.	2018	Brazil	Revista Brasileira de Enfermagem Health Sciences - Nursing SciELO, PUBMED, LILACS, BDENF, WOS, CINAHL	Qualitative study/ VI	Four areas of competencies foreseen in the CompHP model were highlighted: Enable Change, Mediate through Partnership, Communication and Leadership
Netto L, Silva KL, Rua MS.(20)	Analyzing the development of competencies for HP, from the perspective of graduates of a nursing course, and their relationship with the care model.	2016	Brazil	Texto & Contexto Enfermagem ; Text Context Nursing/Health Sciences - Nursing / SciELO	Qualitative study VI	The competencies for HP, defined in the Galway and CompHP consensus, were worked on throughout the training process. The speeches produced demonstrate that the development of competencies for HP can favor the change of the assistance model, despite the challenges in this process. Competencies Advocate for Health, Enable change, Leadership and Mediation through partnerships are present in the speeches.

The number of selected studies, considering the methodological rigor employed, denotes that the discussions on Competencies for Health promotion related to CompHP are still sparse in academia. The fact that CompHP was developed on the European continent, developed and disseminated recently, has shown the novelty of scientific productions that are anchored in this framework. use This occurs mainly when the concentration of publications on competencies for promotion is concentrated on the reasoning of their importance, or on their design and elaboration, with few publications of strategies for implementation in professional training.

For the purpose of describing and discussing the results presented in Chart 1 , we highlight two categories: CompHP competencies development and Health promotion skills teaching, responding to the findings of the selected studies, which were outlined from two approaches: teaching and developing HP competencies (skills, knowledge, attitudes) during nursing training.

Regarding the development of competencies defined in CompHP, studies show that they have been developed during nursing training in Brazil, albeit in an irregular and less than desirable manner.⁽¹⁸⁾Of the 11 domains of the project, only three of them had regularity in studies that sought to recognize the development of CompHP competency domains in nursing training in the Brazilian setting.^(17,19,20)They are: Enable change, Mediate through Partnership and Leadership, which are common in the speeches of students and professors, and indicative of changes in the health care model, even though we have many challenges in this process.^(17,19,20)

Regarding the competencies of the Enable change domain, studies show that these are being developed during nursing training, even if they are not explicitly incorporated into curricula and pedagogical projects.^(18,19)

The studies included in this review demonstrate, through students’ speeches and professors’ knowledge and practices, the recognition and importance of collaborative work for the positive impact of HP actions on the population’s life.^(15,16,20)

The analysis of the studies included in this review reveals a teaching model in transition, with advances in the processes of training and professional education, through innovative experiences, providing an immersion in the professional reality in the initial training periods, interdisciplinarity and a critical professional practice, reflective and collaborative between service-community-professor-student.⁽¹⁶⁾

Despite the advances in the field HP teaching is marked by technical rationality, in order to consolidate the theoretical content, in which the practice is regulated by the professors, providing an experimentation with an ideal and not real SUS, thus offering few possibilities of experiences.⁽¹⁵⁾Furthermore, in the Brazilian context, it was shown that undergraduate nursing professors do not demonstrate ownership of CompHP domains, although these are evidenced in teaching practice.⁽¹⁷⁾

Discussion

The results allowed to show that there is a scientific production that discusses the academic education of nurses with contribution from the CompHP project in the Brazilian reality, demonstrating an interest of the profession in contributing to an integrated look at health and overcoming the biologicist paradigm still present in women. health practices. It is important to highlight that, although the focus of the study was the national reality, international studies that discuss the academic education of nurses with support from the CompHP project were not evidenced. What was found, however, were studies of implementation of CompHP in the European continent, with mention using the project in health education for HP and in professional academic courses, such as medicine and psychology, but not in nursing courses.^(21,22)

Development of CompHP competencies in nursing training

According to CompHP, the Enable change domain “aims to enable individuals, groups, communities or organizations to build capacity for action in HP, and thus improve health and reduce health inequities”.⁽⁸⁾Health is a resource for life, and in order to reach its potential, training through health education and the dissemination of information with appropriate language is imperative. Furthermore, the State must offer resources and opportunities that allow a healthy choice.⁽²³⁾The development of competencies related to the Mediate through Partnership domain involves collaborative work with different areas of knowledge, sectors and partners, in order to increase the impact and sustainability of HP actions, once the conception expanded health is not only ensured by the health sector, but requires coordinated action between governmental and non-governmental sectors.^(8,23)Internships, research and extension projects and the involvement of areas that are still little explored, such as churches, community associations and schools, can provide greater civil engagement.

It is noted that leadership is recognized as a general competency of nurses, being essential for their work. This professional works by leading nursing teams and community health agents, as well as the essence of their work being care, a communication link between multidisciplinary team, patients and institutions.⁽²⁴⁾Leadership can be developed and perfected at graduation; for this, methodologies that encourage the acquisition of skills related to conflict resolution, resource management, teamwork with different sectors and partners, negotiation, decision making are essential in order to form networks of key people motivated to contribute in a shared vision in HP actions.^(8,17)

It is important to note that one of the studies included in this review reveals a reduced concept about HP, with a major mention of disease prevention.⁽¹⁶⁾This fact can hinder the process of developing HP skills in nursing training, since this domain is considered a pillar, permeating all competencies and other domains outlined in the project.⁽⁸⁾It is necessary to overcome the biologicist and preventivist perspective that disengages the political dimension in force in the field.⁽²⁵⁾

Teaching health promotion competencies

The Brazilian National Curriculum Guidelines (DCNs - Diretrizes Curriculares Nacionais ) point to a need for integration of curriculum content, as it favors the teaching-learning process and performance in a multidisciplinary team; however, there is difficulty and resistance in operationalizing this integration,^(15,24,26)since the teaching of HP competencies has been done in a general way and reduced, mainly the course in Pubic Health.⁽¹⁵⁾

The weakness in teaching knowledge regarding CompHP domains, identified in this study, weakens the training of nursing professionals, since some domains, such as Advocate for Health, are fundamental to the claims in favor of users, being recognized as guiding the HP since the conception of the Ottawa Charter.^(17,23)

It is necessary to train professionals with competence in pleading, with the various sectors of society, for the development of public policies, with the capacity to sensitize the opinion of the population and, together with key people, create engagement in order to influence them to develop and maintain actions HP, which positively impact the various health conditions.^(8,23)

In Brazil, it is understood the need to train health workers capable of ensuring the principles and guidelines of SUS and PNPS.^(3,4,27)In recent years, the search for training in this field has increased, and some renowned institutions have created specialization courses in field.⁽²⁸⁾HP is a general competency in nursing training, in which knowledge and skills in the field are reflected in professional conduct and practice.⁽²⁴⁾

In this sense, countless efforts have been made over the past few years, such as encouraging the creation of new pedagogical proposals that provide critical-reflective training and develop competencies, capable of breaking the still existing theory-practice dissociation and changing the health model assistance.⁽²⁶⁾Among them, some have been beneficial to the development of HP competencies, such as using reflective portfolios, home visits, realistic simulation, concept maps and case studies.^(29.30)

However, there are difficulties in relation to using differentiated teaching methodologies that favor the development of ethical, political and social competencies, due to the lack of professor training for using active methodologies.^(26,29)Moreover, the DCNs do not make explicit the content for the development of skills for HP, they only direct the professional profile, and the training institutions have the responsibility to stimulate these competencies in their students.^(24.26)

Am scoping review study corroborates the results of our study, demonstrating the scarcity of assessment studies on impact on practice, education and training, and studies on the implementation and use of HP competencies related to CompHP are rare.⁽²¹⁾In general, scientific productions about competencies for HP focus on describing their construction processes and on the expected positive results of their implementations.^(21,22)

Thus, in order to overcome these aspects, it is believed that the Brazilian reality can benefit from CompHP, even if it has been developed in another socio-cultural reality. National surveys have been beneficial and show that, with adjustments and adjustments of the referential to the Brazilian reality, it is possible to meet the objectives of DCNs and health policies of the country.⁽³¹⁾Thus, we believe that the curricula of nursing courses can be supported by CompHP, in order to guide the training of future nurses and ensure the strengthening of nursing in the HP field.

The fact that we found publications with level of evidence VI highlights the need for studies of another nature, with representations that adequately reflect the profile of higher education institutions in nursing in the country, in order to provide a better understanding and assessment of the impacts of competencies for CompHP HP in practice, education and training.

Conclusion

There is evidence in the literature that the HP competency domains related to CompHP have been developed during nursing training in the Brazilian reality through practical experiences and innovative curricular strategies. However, the data are still exploratory and there is no regularity in the development of these competencies during the nursing training process. Internationally, over the years, HP competencies have been debated and outlined, with a view to a multicultural reality. However, there is still a shortage of studies that show how these competencies can be developed and applied in professional practice. Thus, this study presents experiences of developing competencies for HP and evidence of implementation and teaching strategies that contribute to professional training from the perspective of CompHP. As in the Brazilian setting, we still have a competency benchmark for HP, making it possible to associate CompHP competencies during nursing training. It is believed that the competencies outlined in the CompHP project can be perfectly adapted to guide the training of health professionals, and can be incorporated into the curricula and pedagogical project through teaching that seeks to achieve the minimum knowledge and skills in HP, already identified and proposed by CompHP, with the perspective of training professionals capable of providing more efficient and qualified health care, with improvements in all levels of care. It is hoped that this review study will broaden the discussion of the DCNs in nursing that are in constant development and improvement, so that we can ensure professional standards using mechanisms that ensure the quality and strengthening of nursing in HP. At the same time, it can be used to support discussions in health teams about the competencies necessary for care, as well as empirical research on the implementation of the competencies explored on screen.

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Publication Dates

• Publication in this collection
  14 July 2021
• Date of issue
  2021

History

• Received
  29 Sept 2019
• Accepted
  08 Sept 2020