Competencies in health promotion by nurses for adolescents

Competências na promoção da saúde de enfermeiros a adolescentes

Competencias en promoción de la salud de enfermeras a adolescentes

ABSTRACT

Objective:

to describe the health promotion competency domains, performed by nurses, for adolescents, according to the Galway Consensus.

Method:

a qualitative study based on the Galway Consensus theoretical methodological framework. Fifteen nurses from northeastern Brazil participated. Data were collected between April and May 2017 through pre-structured interviews, submitted to the content analysis technique and analyzed according to the Galway Consensus dimensions.

Results:

the following competency areas were found: catalyzing changes, leadership, needs assessment, planning, implementation, and partnerships. These competencies were contemplated from embracement of adolescents at health unit, guidance, teamwork, educational activities and lectures, as well as active search.

Conclusion:

most health promotion domains were observed; however, it is still suggested that there are challenges to an effective performance of health promotion among adolescents because some competency domains in health promotion have not been evidenced.

Descriptors:
Health Promotion; Adolescent; Nursing; Clinical Competency; Nursing Evaluation Research

RESUMO

Objetivo:

descrever os domínios das competências da promoção da saúde, realizados por enfermeiros, para com adolescentes, segundo o Consenso de Galway.

Método:

estudo qualitativa à luz do Consenso de Galway. Participaram 15 enfermeiros de um município da Região Nordeste, Brasil. Os dados foram coletados entre abril e maio de 2017, por meio de entrevista semiestruturada, submetidos à técnica de análise de conteúdo e analisados segundo as dimensões de Consenso de Galway.

Resultados:

evidenciaram-se os seis domínios do Consenso. Essas competências foram contempladas a partir da recepção do adolescente na unidade de saúde, orientações, trabalho em equipe, realização de ações educativas e palestras, e busca ativa.

Considerações finais:

a maioria dos domínios de promoção da saúde foram contemplados. No entanto, ainda sugere-se que ainda há desafios para o desempenho efetivo da promoção da saúde junto ao adolescente, pois alguns domínios da competência de promoção da saúde não foram evidenciados.

Descritores:
Promoção da Saúde; Adolescente; Enfermagem; Competência Clínica; Pesquisa em Avaliação de Enfermagem

RESUMEN

Objetivo:

describir los dominios de las competencias de promoción de la salud, realizadas por enfermeras, para adolescentes, según el Consenso de Galway.

Método:

estudio cualitativo a la luz del Consenso de Galway. Participaron quince enfermeras de un municipio de la Región Nordeste, Brasil. Los datos fueron recolectados entre abril y mayo de 2017, mediante entrevistas semiestructuradas, sometidos a la técnica de análisis de contenido y analizados según las dimensiones del Consenso de Galway.

Resultados:

se evidenciaron los seis dominios del Consenso. Estas habilidades fueron contempladas desde la recepción del adolescente en la unidad de salud, la orientación, el trabajo en equipo, las actividades educativas y conferencias, y la búsqueda activa.

Consideraciones finales:

se cubrieron la mayoría de los dominios de promoción de la salud. Sin embargo, todavía se sugiere que aún existen desafíos para el desempeño efectivo de la promoción de la salud entre los adolescentes, ya que no se han evidenciado algunos dominios de competencia en la promoción de la salud.

Descriptores:
Promoción de la Salud; Adolescente; Enfermería; Competencia Clínica; Investigación en Evaluación de Enfermería

INTRODUCTION

Health promotion is defined as a process of community training to work on health improvement⁽¹⁾. However, it is significant to emphasize that initially primary care areas, health care for children and women were prioritized, and then, attention to adolescents was considered⁽²⁾.

Nowadays, adolescents have been a target for creating public policies that strengthen health promotion actions aimed at guaranteeing the Millennium Development Goals, aiming at health development for a productive adult life. In this regard, this age group is considered vulnerable, permeated by risk situations such as alcohol and tobacco use, insufficient physical activity, unprotected sexual intercourse and exposure to several forms of violence, which can harm health in the short or long term in terms of biopsychosocial and spiritual well-being aspects^(3-4).

In this context, nursing stands out as a profession for health care promotion as well as for gathering and insertion of adolescents in health-promoting actions in order to reduce the vulnerabilities that adolescents are exposed to and contribute as an instrument of changes in health care practices. Although intense movement and actions aimed at promoting health are recognized, health services may not address adolescents’ needs, since they are people with characteristics of risks, vulnerabilities and demand specific demands of care^(5-7).

It is recommended that the approach model is the one in which adolescents are protagonists as well as the focus of discussions on the reasons for the need for behavioral changes and the search for life quality⁽⁶⁾.

In this perspective, it is needed to search for references and care models that value care actions for specific competencies - with emphasis on the Galway Consensus, held in Ireland in June 2008 - aiming at identifying and developing workforce and competencies for health promotion. In this framework, eight competency domains necessary for effective health promotion are defined: catalyzing changes, leadership, needs assessment, planning, implementation, impact assessment, rights defense and partnerships^(8-9).

Health competency is the ability to accomplish something, in a specific situation, which is related to learning, knowledge acquisition and reconstructing knowledge. Thus, to develop effective health promotion actions, acquiring competencies is a guide for developing professional ability^(10-11).

The Galway Consensus gathers eight domains of health promotion competencies and is inherent to nurses’ work, as it highlights the ability to operate resource management in order to improve their articulation with work and education, and thus optimize health care for the population⁽¹²⁾. Additionally, competencies are essential for health promotion foundation, giving it quality by combining knowledge and competencies in a specialized field of practice⁽¹³⁾.

Nurses’ performance in primary health care needs to incorporate health promotion competencies in adolescent health care. In this context, considering the problem on the referred theme and actions to promote adolescent health, we aimed to answer the following guiding question: what competency domains in health promotion - included in the actions performed - are developed by nurses for adolescents?

This study is relevant because it allows reflecting on nurses’ care practices with adolescents as well as discussing about the inseparable health promotion to nurses’ work, guided by professional competencies, considering the complexity of public health policies.

OBJECTIVE

This study aimed to describe the health promotion competency domains, performed by nurses, for adolescents, according to the Galway Consensus.

METHODS

Ethical aspects

The guidelines and regulatory rules for research with human beings were observed. All participants were informed about the purpose of the study, signed the Informed Consent Form (ICF) and had their anonymity assured. There were minimal risks to participants, such as embarrassment, but it was reduced when discussing the importance of this study for them. This study was approved by the Research Ethics Committee (REC) of Universidade Regional do Cariri and CAAE (Certificado de Apresentação para Apreciação Ética - Certificate of Presentation for Ethical Consideration).

Theoretical-methodological framework

To develop this study, the Galway Consensus theoretical-methodological framework was adopted, which includes eight areas of competency for building global work capacity in health promotion.

The first domain refers to catalyzing changes that correspond to needs for change and individuals’ and communities’ empowerment to improve their health. The leadership domain corresponds to professionals’ strategic orientation for participation and development of healthy public policies in the management of resources for health promotion. The needs assessment domain involves the need to assess the biopsychosocial context of individuals and communities and factors that compromise health^(8,13).

The fourth domain refers to a planning that corresponds to proposing viable strategies in response to assessment of individuals’ and communities’ needs. The implementation domain comprises an effective and active, culturally sensitive and ethical implementation of strategies for health improvement. The impact assessment domain corresponds to determining the scope and effectiveness of the results of interventions planned by professionals. The advocacy domain involves professionals’ work to advocate on behalf of individuals and their community to improve their health and well-being. The partner domain corresponds to collaboration between courses, sectors and partners for promoting health for individuals and communities^(8,12).

Study design

This is a descriptive and qualitative study.

Study setting

This study was conducted with Primary Health Care nurses from a city in northeastern Brazil. Nurses working at Primary Health Care services in the urban area of a city were considered eligible because there were most of professionals.

Eighteen nurses from these health services were eligible. Nurses linked to Primary Health Care services, with at least one year of work experience in that place were included. Nurses who were absent from health services, due to any reason, during the data collection period were excluded. During the data collection period, two were on vacation and one professional, even after scheduling data collection, declared that he was unable to participate. Thus, 15 nurses were interviewed and data collection ended after reaching saturation.

Data source

This study was developed through identification of possible interviewees for the study and contact with nurses and scheduling interviews. Nurses participated of the study after the completion of all described steps. Participants were identified by numbers of ascending order of data treatment and this made it possible to preserve anonymity (nurse 1, nurse 2... nurse 15).

Data collection

Data collection was held through interviews, which took place after scheduling, from April to May 2017, according to participants’ availability, in a reserved space in a health unit, performed individually. Each interview lasted around 32 minutes. The statements supported the construction of analytical categories, characterized by health promotion competency domains. The semi-structured interview script was prepared based on the following question: what actions were taken with adolescents in order to guarantee health promotion in this circumscribed unit?

Data analysis

Interlocution ended after theoretical exhaustion, when the 15 nurses answered the questions asked, so that the findings became repetitive. Thus, this number made it possible to approach the object and identify common themes according to Galway Consensus, which allowed the focus of the study to be reached. All statements were identified by “Nurse”, to identify the interviewees, in order to maintain anonymity, following the number indicating the order of data collection (1, 2, ..., 15).

Then, the findings were submitted to Bardin’s content analysis method, which describes the stages of analysis organization such as pre-analysis, material exploration and treatment of results. After full transcription of all interviews, the text was skimmed, which allowed the corpus definition to be analyzed. The analytical categories were defined, a priori, according to the Health Promotion Competencies framework to Galway Consensus and other studies relevant to the theme.

RESULTS

Participants were predominantly women (13) in relation to the quantity of men (02). The age of nurses ranged between 34 and 40 years old (12 nurses) and from 44 to 51 years old (03 nurses). Concerning time passed after graduation, they were between 11 and 25 years. As for job tenure, there was a variation between 2 and 17 years.

It is presented the categories, evidenced by Galway Consensus domains, performed by nurses with adolescents, aiming health promotion. From nurses’ statements, it was noticed that six domains, from Galway Consensus, were evidenced: Catalyzing changes, Leadership, Needs assessment, Planning, Implementation, and Partnerships.

Catalyzing change

This domain was evidenced through actions to encourage adolescent participation in orientations about body knowledge and disease prevention.

[...] we have just carried out an assessment with children and adolescents students for leprosy. We explain what the disease is, how it is caught, the route of transmission, the importance of knowing the body, the changes that happen in the body... (Nurse 1)

[...] you may be guiding teenagers to health in adulthood. Remember that health is not only the treatment of diseases, but the prevention of these diseases. I advise adolescents to take care of themselves from an early age so that in adulthood they can recognize problems that could put their health at risk. (Nurse 3)

[...] they are open to new ideas, dialogue is easy [...], it is important to prevent many things. (Nurse 6)

Leadership

In this study, the leadership domain stands out for nurses’ initiative to conduct assistance focused on the adolescents’ real needs and health priorities management for this public.

[...] whenever an adolescent arrives, I make it a priority. Because we know that there are many problems inherent to this age group, and that they often seek out colleagues, who do not pass on correct information... so we try to welcome them, with a certain priority, as far as possible. (Nurse 2)

Mobilization of other professionals stands out in order to contribute and multidisciplinary actions, which are encouraged by nurses.

[...] whenever there is a vaccine campaign, which will approach the adolescent public, there must be a different strategy [...], health workers must be better guided in relation to the vaccine issue. (Nurse 4)

Needs assessment

This competency domain is connected to sexual health and its determinants.

[...] they want to know about sexuality, they have a lot of curiosity, doubts, distorted information, which they get with a colleague, with the friend who does and think it is correct... (Nurse 2)

[...] prevention of sexually transmitted diseases, disease prevention and immunization are important. (Nurse 7)

[...] it is a very important phase of discoveries, which does not have that adequate maturity, especially in terms of sexuality. So, you need better monitoring to be able to do everything with maturity and responsibility. (Nurse 14)

The characterization and identification of social problems contribute to recognizing adolescents’ health needs, inferring with the importance of strategies aimed at their reduction and health promotion.

[...] it is complicated to work, especially in a neighborhood like ours [...] there are many vulnerabilities where most adolescents are involved with drugs and everything else, it is very complicated to work on the matter of adolescents here...they are [receptive]. Now, there is the violence issue... I am scared to death [...] because when I arrive [at the periphery] there is more violence [...]. (Nurse 10)

Planning

This domain is evidenced by the awareness that nurses have in relation to staff organization, material, time and educational strategies aimed at adolescents. Additionally, there is an articulation with community health workers in an active search of this public.

[...] the part of planning an educational activity for example, it takes time, knowing who will participate; another thing, I have to be a good articulator, I have to articulate and convince my team to participate. Because I do not do health education alone, and the assistance to adolescents is not only the consultation, the physical examination, it permeates other situations. [...] even the educational strategy you do with adolescents has to be differentiated, [...] every 15 days we met, then we brought a meeting with psychologists, a physical educator, again we brought a military man and each meeting like this one had a different topic. (Nurse 1)

[...] at least once a year I try to do an active search, notes [...] inviting to see the issue of vaccination, it is a way to bring them and also encourage them to make an assessment of their anthropometric status. (Nurse 13).

[...] for adolescents, we think of making meetings to address pregnancy, drug prevention [...] which is common among these doubts. (Nurse 15)

The difficulty in getting support from other agencies goes counterpoint to the needs assessment held by professionals, hindering the intersectoral approach between health and education, being essential for health promotion.

[...] to reach this, we need management support [...] if we schedule a lecture at the health unit, nobody comes [...] which is very difficult to be brought to the user. (Nurse 11)

Implementation

The implementation domain was evidenced through health care for pregnant adolescents, educational lectures and innovative strategies for the audience in general.

[...] I provide assistance to pregnant adolescents who also pass for a consult, the family planning issue. (Nurse 1)

[...] educational lectures with patients. We are intensifying educational lectures during the carnival period: we try to do it. Depending on the season, we change the focus of the activity. (Nurse 2)

This domain is also evident through the practices of search and movement of Community Health Workers (CHWs), making them effective and providing results.

[...] I try somehow, or through lectures and also theaters to call their attention to come, when we don’t have to go to them and search more at schools. (Nurse 8)

[...] we talk on Sexually Transmitted Diseases [STD], alcohol, drugs. We search for Community Health Workers [CHWs] and they come. A good amount comes and they are very receptive. (Nurse 5)

Partnership

Partnership is noticed mainly by the mutual cooperation between nurses and school as well as articulation and assistance from the Family Health Support Center (FHSC).

[...] activities are a little punctual, for example, we go to school to perform visual acuity activity, then we take this opportunity to tell them that there is a service, that they can look for it, that they can answer their doubts with health workers about the type of service offered. Then, we encompass the issue of body hygiene, body care, etc. [...] another facility is access to the geographical area, the health unit is very close to the school. Another facility is about the health workers [...] because they are very proactive and very fond of performing educational activities. (Nurse 1)

[...] the schedule is made with the coordination of the program and the school. This means there is a meeting between health professionals and the school pedagogical director. (Nurse 3)

[...] to go to schools, because going after adolescents instead of they come to professionals. We use the CHWs and parents we already know, because since I have been here for more than nine years, I already know almost all parents in the Community. (Nurse 8)

[...] we work at school even though it is in elementary school because we still have adolescents at the beginning of this phase. (Nurse 9)

[...] there is an assistance from the Family Health Support Center [FHSC], which is a good partnership for us because it is going to be useful. (Nurse 13)

The intersectoral nature of actions contributes to adolescents’ health in which they are encouraged to know and seek other support services, contributing not only to prevention, but also to comprehensive care.

[...] in partnership with all professionals we have at FHSC, in which we try to create some strategy to try to bring these adolescents. For example, now, our physical educator is setting up a group of adolescents that did not exist, by modifying the random service model according to demand. (Nurse 12)

[...] we always look for the school, we set up a calendar. For instance, for April, then we set up as best for the school and for us, then the educators organize it in classrooms, in auditoriums, like us too and we are already going there. (Nurse 8)

DISCUSSION

The emerging necessity to develop competent in health promotion by nurses is fundamental for defining the essential competencies in this field, which can be important for building a new care model focused on adolescents.

The Catalyze Change competency empowers individuals and the community to improve their health, encouraging change production^(8-9). From the data found, this competence is contemplated by nurses when they portray the search for improvement in welcoming adolescents and eliminating barriers between this public and the Basic Health Unit through guidance on diseases and the importance of knowing the body and disease prevention, empowering adolescents taking care of themselves at this stage to eliminate possible health risks in adulthood.

It was also emphasized the importance of inserting themes that go through the changes that occurred in adolescence, something recurrent in the health education of this public. The nurses’ statements in this study emphasizes neglected diseases such as leprosy, which are also emerging. These characteristics provide greater autonomy and self-care in adult life.

It is possible to observe the primary health care process challenge concerning implementing organized, effective and specific actions for adolescents; most of time, it seems that there are no actions focused on the specificities of adolescence. Besides that, the inexistence of innovative strategies and captivating approaches, due to the deficit of continuing education of professionals, leads to resistance from this public^(14-15).

According to the Galway Consensus, the leadership competency deals with directing strategies that support healthy public policy development, resource mobilization and management for health promotion and capacity building^(8-9). The leadership competency indicates the need for greater actions aimed at this audience, considering the difficulty of adolescents to seek primary health care services.

Determining the scope, effectiveness and impact of health promotion policies and programs includes an appropriate organization of evaluation and research methods to underpin program improvement, sustainability, and dissemination⁽¹⁶⁾. In this research, nurses sought for optimizing the entry of adolescents into the health service and perform strategies for specific actions, such as vaccination. This action is important for disease prevention and link formation between professionals and adolescents.

Needs assessment is related to analysis of social, cultural and environmental conditioning as well as of organizational determinants that favor health promotion or commitment^(8-9). The public at which this study is focused reported the need for strategies directed to sexuality and drug use prevention among adolescents. These findings are consistent with a study that highlighted nurses, as trainers and educators, have the basic function of assessing and knowing the environment in which these adolescents are inserted, in order to identify their vulnerabilities and needs in the biopsychosocial context⁽¹⁷⁾. In this study, health promotion aimed at leprosy assessment and knowledge stands out. Such point of view differed from other perspectives and may be related to the reality of the region studied.

Planning is interrelated to needs assessment, and aims at determining plausible and achievable goals as well as strategies based on theories and scientific and practical evidence^(8-9). This research exposes the articulation of Community Health Workers in the search for adolescents, organization of educational actions regarding material and personal resources, and active search of adolescents as a strategy to attract and insert them in the health unit.

Establishing a bond with adolescents is a perceived barrier in health services. In this field, it is emphasized using theoretical knowledge to develop nursing actions aiming at promoting health⁽¹⁸⁾.

Published studies^(19-20) bring the qualification of primary health care through activities with adolescents in groups, educational and health promotion actions, whose positive results are related to the factors that aroused adolescents’ interests, such as methods used that favored dialogue, exchange of experiences and reflection on their own practices, relationships with groups of friends/families. Developing such actions is justified by the low frequency of adolescents in health services, which requires assertive activities involving them. Moreover, the involvement of adolescents facilitates identifying facilitating and inhibiting factors to promote essential health strategies^(14,21).

The implementation competency is characterized by the effective and efficient realization of ethical and culturally accepted strategies in order to ensure possible improvements to health including planned actions, which involves human and material resources^(6-7,22).

In this competency, it is observed the implementation of broad actions, directed to the most common problems faced by this public, such as Sexually Transmitted Infections, drugs, alcohol and sexuality. The breadth of these themes is fundamental since the vulnerabilities found by this population and the need for diverse actions in order to enable prevention of diseases in this period of life that may influence adult life.

It is perceived that implementation, planning and partnerships competencies are interconnected, emphasizing the presence of family and school as essential links to health promotion. This connection is also noticed in other studies, basing its importance to health⁽¹⁸⁾. Intersectoriality and partnerships with other institutions are important for the effectiveness and success of developed actions. The school has an essential role in this competency as well as sending adolescents to another professional in order to promote a complete care.

There are other studies which corroborate by stating the correlation of catalyzing change, leadership and partnerships domains with health promotion implementation⁽¹²⁾. It is important to stress the need for planned and systematized educational interventions by nursing, with emphasis on educational technologies for health promotion, considering their attractiveness for adolescents and potentiator of their autonomy^(23-24).

In order to make these competencies effective, nurses must act as learning and empowerment facilitators, transforming themselves into health promotion workers. When followed, the competency domains play a fundamental role in changing the medical-hegemonic and disease-centered model. Thus, it is highlighted the relevance for nursing as a profession inseparable from health promotion, following these competencies and acting under a new perspective, centered on adolescents as a whole, considering their aspirations for a better interaction between nurse and adolescent⁽²⁵⁾.

The partnerships competency is related to cooperation between courses, sectors and partners in order to improve impact and sustainability^(6-7). Health promotion actions, performed in partnership with other health professionals and other sectors of society, encourage the leadership of community members, which allows the dissemination of self-care for health and positively impacting the lives of adolescents and health services⁽²⁶⁾. Despite the partnerships reported by nurses in this study, it is still observed that there may be difficulties regarding low demand for health services, by adolescents, and little attention to care actions.

The school acts as an important partner in promoting health for adolescents. Thus, partnerships between health and education should be encouraged as they facilitate assistance to adolescents aiming at preventing and improving their health⁽²⁷⁾.

Nurses’ partnership with Community Health Workers encourages the participation of adolescents in health services. This leader is a mediator between the health team and the community. Community Health Workers, through the adolescents’ active search for services, contribute to promoting adolescents’ health. Moreover, it can identify health problems that need intervention. Thus, it strengthens and encourages the search for health care⁽²⁸⁾.

Health impact assessment and advocacy domains have not been raised in the interviewees’ statements. However, it was found that the actions developed by nurses sought to promote the health of this population. In this context, they allowed health promotion optimization with adolescents, emphasizing the adequacy to the reality of health actions for the population studied.

Limitations of the study

This study is limited by the fact that part of inferences come from a particular context, and probably not possible to be generalized, due to the influence of cultural, economic and political factors inherent to the region in which this study is concentrated. Semi-structured script use was another limitation of the study. To this end, nurses were offered the possibility of adding, during the interview, other perceptions in relation to their work with adolescents. Therefore, other investigations are necessary for the generalization of the findings in similar realities.

Contributions to nursing, health, and public policies

This research contributes to nursing and has practical implications concerning studies on nurses professional competencies as they are seen as an inseparable aspect of a nurse’s job, in his or her professional practice and in the development of public policies.

FINAL CONSIDERATIONS

The nurses’ statements portrayed the following areas of health promotion competency in the Galway Consensus: catalyzing change, leadership, needs assessment, planning, implementation and partnerships.

Among the health promotion competencies areas of the Galway Consensus, two have not been highlighted: Health Impact Assessment and Advocacy. It suggests that there is a need for working them to the effective professional performance of nurses. Thus, such aspects may impact health promotion of adolescents. The evaluation and feedback of planned intervention actions and the search for adolescents’ rights to public health policies is considered relevant.

It is realized the importance of the applicability of Galway Consensus competencies, considering the benefits offered to individuals and community, contributing to a full and healthy experience of adolescence, enhancing adult life.

In this regard, it is suggested that promoting adolescent’s health, based on these competencies, should be enhanced and motivated, through continuing education of nurses and necessary subsidies for effective actions to promote health.

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Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Fátima Helena Espírito Santo

Publication Dates

• Publication in this collection
  04 June 2021
• Date of issue
  2021

History

• Received
  18 Apr 2020
• Accepted
  30 Aug 2020