Nurse’s competences in promoting women’s health in light of the Galway Consensus

Las competencias del enfermero en la promoción de salud de la mujer a la luz del Consenso de Galway

ABSTRACT

Objectives:

to identify nurses’ competences in promoting women’s health.

Methods:

descriptive study with a qualitative approach that adopted the Galway Consensus as a theoretical-methodological framework. Data collection was performed through semi-structured interviews.

Results:

most of the Galway Consensus’ competence domains were present in the nurses’ interventions related to health promotion in women’s care. “Assessment of needs” and “Implementation” were the most highlighted domains, followed by “Leadership” and “Impact assessment”. The domain “Defending/Advocating Rights” was not identified.

Final Considerations:

within the nurses’ work with women, some of the Galway Consensus domains of competencies for health promotion were present. However, there is a need, in the context of continuous health education, to expand strategies and enhance the development and application of these health promotion competences.

Descriptors:
Health Promotion; Women’s Health; Competency-Based Education; Role of the Nursing Professional; Public Health Nursing

RESUMEN

Objetivos:

identificar las competencias de enfermeros en la promoción de salud de la mujer.

Métodos:

estudio descriptivo con abordaje cualitativo que adoptó el Consenso de Galway como referencial teórico-metodológico. Recolecta de datos fue realizada por medio de entrevista semiestructurada.

Resultados:

mayoría de los dominios de competencias del Consenso de Galway fueron contemplados en las intervenciones del enfermero relacionadas a promoción de salud en el cuidado a la mujer. “Evaluación de las necesidades” e “Implementación” fueron los dominios más evidenciados, seguidos de “Liderazgo” e “Evaluación del impacto”. No fue identificado el dominio “Defensa de derechos”.

Consideraciones Finales:

en el trabajo de los enfermeros con las mujeres, hubo la presencia de algunos dominios de las competencias de promoción de salud del Consenso de Galway. Pero, hay necesidad, en el ámbito de la educación permanente en salud, de ampliar estrategias y potencializar el desarrollo y aplicación de esas competencias de promoción de salud.

Descriptores:
Promoción de la Salud; Salud de la Mujer; Educación Basada en Competencias; Rol de la Enfermera; Enfermería en Salud Pública

RESUMO

Objetivos:

identificar as competências de enfermeiros na promoção da saúde da mulher.

Métodos:

estudo descritivo com abordagem qualitativa que adotou o Consenso de Galway como referencial teórico-metodológico. A coleta de dados foi realizada por meio de entrevista semiestruturada.

Resultados:

a maioria dos domínios de competências do Consenso de Galway foram contemplados nas intervenções do enfermeiro relacionadas à promoção da saúde no cuidado à mulher. “Avaliação das necessidades” e “Implementação” foram os domínios mais evidenciados, seguidos de “Liderança” e “Avaliação do impacto”. Não foi identificado o domínio “Defesa de direitos”.

Considerações Finais:

no trabalho dos enfermeiros com as mulheres, houve a presença de alguns domínios das competências de promoção da saúde do Consenso de Galway. Porém, há necessidade, no âmbito da educação permanente em saúde, de ampliar estratégias e potencializar o desenvolvimento e aplicação dessas competências de promoção da saúde.

Descritores:
Promoção da Saúde; Saúde da Mulher; Educação Baseada em Competências; Papel do Profissional de Enfermagem; Enfermagem em Saúde Pública

INTRODUCTION

The Family Health Strategy (FHS) emerged as a branch of expansion and qualification of access to actions and services within the scope of Primary Health Care and allowed for greater interaction and approximation of activities within a delimited territory in order to propose improvements for coping with problems identified in loco(¹). The FHS is characterized by a set of health actions, in the individual and collective spheres, covering health promotion, protection, disease prevention, diagnosis, treatment, rehabilitation, harm reduction, and health maintenance, to improve the situation of people’s health(²).

The presence of nurses in the FHS is essential for the dissemination and consolidation of this health care strategy, as well as for the reorganization of the care model. This is because the nurse has essential attributions, which, as a whole, range from the organization of the activities of the FHS to the direct care assistance of the individual, family, and community(³).

Among these attributions are health promotion actions, which aim to support, understand and guide, more broadly, the methods and strategies for individuals to maximize control over their own health. Therefore, it is important that nurses are prepared, as of their training process, to perform such actions through competences, so that there are positive results among the population receiving care(⁴-⁵).

In order to expand professional training based on competences, the Galway Conference was held in Ireland in 2008, which resulted in a document developed through a worldwide collaboration for the development of essential competences related to health promotion. “Competence” was defined as the ability to apply the knowledge acquired through skills and attitudes to achieve a concrete result(⁶-⁷).

The Galway Consensus statement, when describing fundamental values and principles, defined eight domains of essential competences to develop effective health promotion practices(⁸), namely: 1. Catalyzing change; 2. Leadership; 3. Assessment of needs; 4. Planning; 5. Implementation; 6. Impact assessment; 7. Defending/advocating rights; 8. Partnerships(⁹).

In the field of health promotion, the development of competences contributes to the formation of more competent professionals, confident in their behavior, encouraging the provision of evidence-based services focused on care for the client, family, and community; and constitutes the basis for responsible practice and quality assurance, meeting the principles disclosed in Ottawa(¹⁰).

In the Ottawa Charter, essential strategies for the application of health promotion were described, which are fundamental in the performance of professionals, namely: implementation of healthy public policies, community training, development of individual and collective skills, and reorientation of health services(¹¹).

In this sense, there is a need to know how the process of developing nurses’ competences in health promotion occurs, involving care for the population assisted by the FHS, especially women’s health. This is because women are the ones who most seek health services and are more vulnerable to imposed social stigmas, violence, rigid social standards, and weaknesses in social and economic status; therefore, they are more susceptible to the risk of contracting disease or minimizing health care(¹²).

Given this situation, the following question was posed: What are the competencies developed by nurses in health promotion involving women’s health care in the light of the Galway Consensus?

It is proposed, with this study, to identify how nurses operationalize the competencies in their territories with regard to the promotion of women’s health and, based on this, to propose actions to align the activities carried out with the competencies defined by the Galway Consensus, since the effective care provided by this professional interferes in a beneficial and resolute way in the FHS. It is known that health promotion practices are essential as they directly impact the health of the communities in which they are inserted. Thus, the relevance of this study is to contribute to a critical reflection on nursing care practice related to the competencies for promoting women’s health.

OBJECTIVES

To identify nurses’ competences in promoting women’s health.

METHODS

Ethical aspects

The study complied with Resolution No. 466/2012 of the National Health Council. Participants signed the Informed Consent Form and the Post-Informed Term. The project was recognized by the Ethics and Research Committee.

Theoretical-methodological framework

Competencies are developed in order to qualify and guide professionals on the effective performance of their functions. In this sense, it is necessary to present, in the context of health promotion, the competences of the Galway Consensus as a guide for work in defense of the promotion of women’s health (Chart 1).

Chart 1
Health promotion competence domains proposed by the Galway Consensus, Brejo Santo, Ceará, Brazil, 2021

Domain	Objective
Catalyzing change	To enable change and empower individuals and communities to improve their health.
Leadership	To provide strategic direction and opportunities to participate in the development of healthy public policies, mobilizing and managing resources for health promotion, and capacity building.
Assessment of needs	To assess needs in communities and systems that lead to the identification and analysis of the cultural, social, environmental, and organizational behavior of determinants that promote or compromise health.
Planning	To develop measurable goals and objectives in response to the assessment of needs and identify strategies that are based on knowledge derived from theory, evidence, and practice.
Implementation	To effectively, efficiently, in a culturally sensitive and ethical manner, carry out strategies to ensure improvements in health, including the management of human and material resources.
Impact assessment	To determine the scope, effectiveness, and impact of health promotion programs and policies. This includes the use of evaluation and research methods to support program improvements, sustainability, and dissemination.
Defending/advocating rights	Advocate with and on behalf of individuals and communities to improve their health and well-being and build their capacity to take actions that can improve health and strengthen community assets.
Partnerships	To work collaboratively with areas, sectors, and partners to improve the impact and sustainability of health promotion, programs, and policies.

⁶

Study type

Qualitative study that adopted the Galway Consensus as a theoretical-methodological framework, as it described the competencies developed by nurses in promoting women’s health. The COREQ script was used for data collection.

Methodological procedures

To carry out this study, the following steps were taken: 1) contact was made with the Health Department for consent and access to the FHSes; 2) identification of rural and urban FHS teams; 3) access to FHSes and scheduling of interviews with participants. Nurses working in the FHS teams in urban and rural areas participated in the study, after following the steps mentioned, approval of the research by the ethics committee and signing of the Informed Consent Term and Post Informed Term.

Study scenario

The research had as locus the Basic Health Units of a municipality in the region of Cariri, state of Ceará, Brazil. Data collection took place in October 2018.

Data source

For the selection of study participants, the following inclusion criteria were defined: 1) nurses working in the FHS; 2) working at the FHS for at least six months. Nurses absent, for any reason, from the health service during the period of data collection were excluded.

In total, there were 19 nurses working in the FSH teams. However, two were not available to participate in the research, and one nurse was away from the position for health reasons. Thus, 16 nurses were selected.

The nurses’ identification information were kept confidential through the use of the word “Nurse” followed by the number representing the order in which the interview took place. After surveying the existing FHSes in the city, which totaled 19, the main researcher visited them and invited possible participants to the research. Subsequently, the eligibility criteria were applied. Nurses were invited to participate in the research; and, for those who expressed interest, a schedule was made according to their availability.

Data collection and organization

Information was obtained through semi-structured interviews with questions about the nurses’ sociodemographic and professional characteristics and related guiding questions: What activities do you develop towards the promotion of women’s health? What are the possible difficulties in carrying them out in your daily work?

The interviews were carried out in the nurse’s work room, at the Basic Health Unit, with the purpose of offering privacy to the participants; and were recorded and transcribed for further analysis.

Data analysis

The analysis of the collected information was based on the content analysis technique, a thematic modality that aims to unveil the core meanings that make up communication(¹³).

The material was transcribed and analyzed following three phases of analysis. In the first phase (pre-analysis), we sought to do a detailed reading, followed by organization and formulation of hypotheses. Afterwards, the exploration of the material was carried out in order to aggregate, code, and classify the data. In the last step, the data went through a process of interpretation and delimitation of the themes, according to attributed meanings(¹³). The analyzed data are categorized and evidenced according to the highlighted domains, in the light of the Galway Consensus, in women’s health promotion activities.

RESULTS

Regarding sociodemographic characteristics, it was evident that, of the 16 study participants, 12 were female. Age ranged from 31 to 60 years. As for marital status, eight nurses declared themselves married; and eight, single. The time since academic training ranged from 5 to 37 years. Information regarding the length of experience in the FHS highlighted that seven nurses worked between one and five years, five worked between seven and ten years, and four nurses worked between 12 and 17 years.

With regard to the titles of the participants, the specialization in family health was the most reported, being covered by eight nurses. Other specialties cited were intensive care (2), urgency and emergency (2), health management (2), worker’s health (2), public health (1), obstetrics (1), and auditing (1). It is noteworthy that four participants did not report any degree and that five participants had more than one specialization.

In the narratives, it is possible to identify the consonance with the competences based on the Galway Consensus. “Assessment of needs” and “Implementation” were the most evidenced competence domains, followed by “Leadership” and “Impact Assessment”, as can be seen in Chart 2. It is also highlighted that it was not possible to identify the domain “Defending/advocating rights”.

Chart 2
Nurses’ competence domains regarding the promotion of women’s health according to the Galway Consensus, Brejo Santo, Ceará, Brazil, 2018

Competences	Nurses Practices
Catalyzing change	[…] regarding the prevention of cervical and breast cancer, from time to time I’ll do an educational practice […] I do it as a means of encouragement, I also usually provide waiting room patient education, I take advantage of moments during other situations to be able to talk about it. (Nurse 2) […] I like to bring women together to talk, to clear up any doubts, to try to encourage prevention. (Nurse 9) […] I try to hold meetings with the community, with the women […] I like to get women together to talk, ask questions […]. (Nurse 4)
Leadership	[…] to attract women to the FSH, there are lectures, conversation circles, gift raffles, a beauty task force, and distribution of gifts. (Nurse 11) […] we used several strategies, lectures, the third shift in October, rapid test for human immunodeficiency virus [HIV] and syphilis […]. (Nurse 7) […] active search for this audience alongside health agents. (Nurse 16)
Assessment of needs	[…] structural issues that limit access and compromise the quantity and quality of the services provided. (Nurse 11) […] I mention the cervical cancer prevention exam, as I perceive a low demand due to the woman’s resistance to being exposed to a male professional. (Nurse 7) […] it’s more a question of available materials, even educational materials themselves that we don’t receive […] the permanent education that we even try to do, but it doesn’t really work out. […] a difficulty in family planning, the woman does not want to come only for guidance, if she’s not also going to obtain medication, she won’t come. Regarding the prevention of cervical cancer, we had a very big drop due to the issue of delay in results. (Nurse 14) […] I miss having care protocols, that municipalities established protocols that guide us in care, this is a difficulty […] the lack of these protocols. It interferes in the execution of activities, in the prescription of medications. (Nurse 2) […] the nurse is allowed to request a mammogram but not an ultrasound; however, they are complementary exams. […] the service is often overcrowded because it relies on the doctor […]. (Nurse 13)
Planning	[…] holds a meeting with the team, exposes the situation, highlights the items with a low indicator so we can find a way to improve this indicator. (Nurse 14)
Implementation	[…] gynecological and prenatal care, combating violence against women, family planning, climacteric assistance, and assistance to black women and the lesbian, gay, bisexual, transvestite, transexual, or transgender people. (Nurse 5) […] prenatal care, family planning, cervical cancer prevention, early cancer detection, immunization program and health education. (Nurse 1) […] monitoring of women since adolescence with vaccination, guidance on sexuality, all from an early school age […] lectures, provide adolescents with information regarding sexuality and family planning. (Nurse 15) […] the importance of prevention […] but, in any case, they eventually seek us out if we compare it to men’s health. It is a good strategy, a good action, because through it many diseases are fought and prevented. (Nurse 10) […] it is to provide daily human assistance that considers the different profiles of women and their needs […]. (Nurse 12) […] we carry out immunization, family planning, cytopathological screening, planning, nutritional screening and, thus, a schedule is made […]. (Nurse 6)
Impact assessment	[…] I believe that this practice [women’s health] has been developed very intensively and with optimal acceptance by this audience. (Nurse 7) […] we work a lot with health indicators […] we touch base with the basic attention to see what we can improve in these indicators. (Nurse 14) […] in women’s health, the best response I get is with prenatal care, let’s say that our attendance level is 100%. (Nurse 3)
Partnerships	[…] We have the multiprofessional residence that contributes a lot to the women’s health care. (Nurse 14) […] I like to always ask Community health agents [CHAs] for help so that they, during the home visit, orient these women on the importance of taking care of themselves and bring these women here. (Nurse 2) […] we have a partnership with the Social Assistance Reference Center [SARC]. We are trying to organize groups, however, many groups are still restricted, such as the regnant women’s group […]. (Nurse 8)

DISCUSSION

The development of health competences relates to individual work, which involves the form of the production of health work(⁷). In addition, it is a propeller in the formation of professionals integrated with public health policies focused on the attention and reorientation of the integrality of health care.

The competence domain “Catalyzing changes” capacitates individuals and communities to improve health by fostering the production of changes through the empowerment and autonomy of the subjects, being a health practice’s instrument of transformation(¹⁴). Of the evidenced findings, this competence is contemplated by nurses when they encourage and stimulate women from their community in this competence through educational practices and conversation circles on women’s health issues.

Health educational actions can empower women to construct new knowledge and knowing, which will revert in preventive or health promotion actions(¹⁴). Empowerment is one of the pillars that support health promotion; it makes the subject jointly responsible for and provides him autonomy regarding his own health(¹⁵). Nurses play a crucial role in enhancing women’s autonomy due to the approach with this clientele.

According to the Galway consensus, the “Leadership” domain must contain the direction of strategies that compete for the development of healthy public policies, and mobilization and management of resources for health promotion and capacity building. In addition, leadership provides improvements in performance and the quality of work(¹⁶). In this sense, the Nurses’ initiative stands out in conducting assistance focused on the real needs of women and in the management of specific priorities for this public. The identified speakers refer that the leadership competence is inherent in their professional performance, in the process of health promotion, as it leads and encourages educational practices in the community through active search and mobilization of this clientele.

Active search strategies are developed in the community itself so that women participate in health promotion activities carried out in the FHSes and are enabled by the bargaining to attract the target audience. Another evidenced strategy was the use of a third shift for women’s health care. Thus, nurses seek to attract these women and carry out specific actions.

Leadership is the domain of competence that allows the health professional to produce one or several strategic directions that leverage improvements. Regarding this competence, the nurse is considered the most capable professional to act as a leader, aiming to implement and carry out health promotion actions. Therefore, nursing leadership can produce changes in care systems, establishing partnerships and adequate communication between professionals and the community. Still, it is highlighted that nurses can lead teams as well as support other professionals through supervision and dialogue(¹⁷-¹⁸).

The competence domain “Assessment of needs” was the most evident in the nurses’ statements. It can help guide nursing interventions in defense of improvements in women’s health. Furthermore, this domain significantly contributed to health promotion actions, as this assessment allows knowing the needs presented by users so that measures can be implemented to circumvent and resolve them(¹⁹).

Nurses reported structural needs such as the lack of some materials and supplies, as well as educational instruments for health education activities. This is problematic, as the presence of these elements can help increase these women’s adherence and improve the work performed by nurses. The standardization of municipal nursing protocols, as instruments that guide the actions performed by nurses, can expand the capacity of operationalization and resolution of nursing actions.

In Brazil, the Law on Professional Nursing Practice (7,498/86) guarantees that nurses, as members of health teams, can prescribe medication approved in public health programs and in a routine approved by the health institution. Therefore, care protocols are essential in conducting nursing care. According to Ordinance No. 2.436/17, which approves the National Policy on Primary Care, the duties of nurses working in Primary Care are described: carrying out nursing consultations, requesting additional tests, and prescribing medications, following the legal provisions of the profession in compliance with protocols or other technical regulations established by the Ministry of Health. Such elements demonstrate the autonomy that these professionals can and should exercise in the health service(²-²⁰).

Along with population aging and the prevalence of chronic diseases, the prescription of medications performed by nurses has been the object of international debate. In this context, other health professionals have their responsibility expanded to meet the new demands of the population(²¹).

Thus, this “Assessment of needs” competence domain guides and orientates the actions that nurses should follow. Furthermore, it is directly linked to the “Planning” and “Implementation” domains. While the “Planning” competency domain is related to goals and objectives outlined based on the diagnosis of the problem identified by the assessment of needs, implementation is the effective way to develop previously planned actions(¹⁴).

This research points out that the nurses’ articulations in knowing the health indicators can be expanded and improved through meetings with team professionals and intersectoral articulations for solutions and improvement of these indicators. It also indicates that there must be proposals for the decentralization of services provided, based on prevention, promotion, and recovery of these women’s’ health.

The “Implementation” competence domain seeks to effectively and efficiently implement strategies to ensure possible improvements to health and involves human and material resources(²²). In this competence, it is possible to observe the implementation of broad actions aimed at the problems most faced by this public, in the context of vaccination, monitoring of adolescents in schools, and educational lectures.

In this way, studies show the importance of strong implementation strategies involving partnerships between all professionals of the Basic Health Units, as it could be possible to have a broad portrait of the community and the consequent development and encouragement of the use of specific techniques and processes to promote quality health(²³). The expansion of strategies for other sexual and gender minorities (lesbians, gays, bisexuals, and transsexuals) can be encouraged since this population has less adherence to preventive exams for fear of stigma and discrimination. Thus, it is up to the FHS professionals to actively search for this public(²⁴).

Another aspect highlighted by the participants was the promotion of sexual/reproductive health, related to cancer prevention, prenatal care and, mainly, family planning. Although it is recognized that family planning is important for maternal and child health(²⁵), other themes could be expanded to strengthen the health promotion of these women, considering the analytical category of gender and their singularities. The focus on family planning is justified, in part, by the fact that women’s health was, for a long time, limited to the reproductive and biological aspect, under a strong patriarchal influence in the domination of female bodies(²⁶), being also allied to the culture of compulsory maternity(²⁷).

The “Impact Assessment” competence domain supports interventions to improve health programs aimed at disseminating the strategies used(¹⁹). The impact assessment was evidenced in the women’s health program as a well-accepted strategy, as women are assisted in health units in the context of the life cycle. The impact assessment is essential in the practice of health promotion by allowing and observing how the actions promoted both by individual professionals and by the health system contributed to the users’ lives. With this, it is possible to identify new needs and/or priorities for changes in order to increase equity in health(²⁸).

However, it is noteworthy that one of the most present evidence in the impact assessment was the adherence of women to prenatal consultations. Once again, it seems that this aspect stands out due to the historical context of women’s search for health services for attention to reproduction and sexuality aimed at gestational care. However, reproduction and sexuality are polarized points that must be discussed in different ways. These are important aspects for the autonomy and guarantee of women’s health, also considering the need to focus on actions that contribute to the insertion of men in the context of sexual and reproductive health, which is often denied by social taboos(²⁹).

The “Defending/advocating rights” competence domain highlights the need to establish a relationship between the health area and the area of law. Thus, the professional could act in a broader and more autonomous way(³⁰). In the present study, this competence domain was not evidenced. This domain highlights the importance of the nurse as an articulator of actions that favor health advocacy and, thus, also enable the autonomy and empowerment of the user in view of the proximity bond that the FHS provides, the possibility of empowering women about their rights, and duties towards health services and social rights.

Regarding the “Partnerships” competence domain, in the quality of cooperative work between disciplines, sectors, and partners to improve the viability of health promotion programs and policies(³¹), they were perceived to occur through the relationship between professionals in the multiprofessional residency and community health agents (CHA). Such partnerships contributed to the promotion of women’s health, impacting the health and life of this public in health services, as they collaborated both in the guidance and in the active search of women for health actions.

The multiprofessional residency in health, in one of its guiding pillars, supports health education using knowledge acquired in theoretical and training processes. In addition, professionals can identify the complexity of health determinants and, thus, effect changes in care practice, through teamwork, knowledge exchange, and health practices. With this, it is possible to develop health promotion actions that are more effective and adequate to the realities of the communities(¹⁰).

Considering the above, the importance of inserting knowledge about health promotion competencies in nursing curricula is verified for the training of nurses with skills to act in a comprehensive, transdisciplinary, and equitable manner, with a focus on the population’s health, to the detriment of the biomedical model(¹⁰). In Primary Health Care, the demands are plural, advocating a professional performance with the ability to use new technologies of high complexity and low density, capable of carrying out educational actions in order to contribute to changes in behavior that influence the individual’s health, enabling health promotion(³²).

Nurses, endowed with essential competences in health promotion, play an important role to ensure a holistic look and implementation of actions, allowing reflection on health practices and contributing to the process of permanent change(²²). Although most domains of health promotion competence have been highlighted, there is an implicit critical reflection that the competence of defending/advocating rights can be developed by nurses. Thus, it would be important to carry out training with such professionals regarding the appropriation of these competences related to health promotion.

Study limitations

The interpretation of the results is considered one of the main limitations, as it refers to a particular context in which actions aimed at promoting women’s health were investigated. Therefore, it is suggested that the study be expanded to consider other perspectives.

Contributions to the field of Nursing, Health or Public Policy

The importance of the nurse as a health promoter in the community is highlighted, considering the competence domains related to health promotion. Thus, it will be possible to enhance the promotion of women’s individual health in order to make them the protagonist of their own health care.

FINAL CONSIDERATIONS

The identified competence domains developed by nurses in health promotion related to women’s health were: Catalyzing change, Leadership, Assessment of needs, Planning, Implementation, Impact assessment, and Partnerships. The competence domain “Defending/advocating rights” was not perceived.

Although each domain has developed independently, in different contexts, they presented contributions related to the promotion of women’s health in these communities. However, there is a need, especially in the context of continuing health education, to bring together ways to improve the development and application of these domains related to health promotion so that nurses may feel prepared to develop the domains of competence in actions to promote health.

The results of this study may support nurses’ behavior towards more effective health promotion practices; and encourage them to adopt the most effective and resolute strategies in their professional performance scenarios.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Hugo Fernandes

Publication Dates

• Publication in this collection
  02 Feb 2022
• Date of issue
  2022

History

• Received
  06 June 2021
• Accepted
  30 Sept 2021