Professional competencies to promote health in nursing and physical education undergraduate courses

Rev Bras Enferm. 2021;74(2): e20200617 https://doi.org/10.1590/0034-7167-2020-0617 9 of ABSTRACT Objectives: to recognize the competencies for health promotion and their magnitude of expression in undergraduate health education based on the analysis of the pedagogical projects of the courses and from the teaching perspective. Methods: research with a mixed approach, carried out at a public university. The data collected from the pedagogical projects of the Nursing and Physical Education courses and through interviews and application of a matrix of Competencies in Health Promotion with 31 professors of the referred courses were analyzed in the light of Competencies Health Promotion. Results: all competencies investigated were recognized in the curricula and reports of nursing professors, but the possibility of changes was not identified in the pedagogical project of Physical Education, although this competency was recognized as extremely important by the professors, with a mode of 4.5. Final Considerations: the training process in the courses studied has favored the development of skills for health promotion. Descriptors: Health Promotion; Health Personnel; Professional Competency; Nursing; Physical Education and Training.


INTRODUCTION
The incorporation of health promotion as a public health paradigm triggered discussions about the adequacy of professional training to work in this field. In Brazil, these debates are converging with the continuous attempt to ensure that the principles of universality, equity and social participation of the Sistema Único de Saúde (SUS) (Unified Health System) are effectively addressed in health care.
Related to this panorama, the National Curriculum (NC), the guiding instrument for professional health education, defines the fundamentals and principles for academic training. The objective is to obtain a profile of graduates with competencies to act in health care through the development of health prevention actions, health promotion, protection and rehabilitation (1) .
Some professional skills, here recognized as a combination of abilities, attitudes and knowledge necessary for performance in the health field (2) , pointed out by the NC are health attention, decision making, communication, leadership, administration and management, and continuing education (3) . However, these competencies are very broad, not specifying what actions are necessary to achieve them to establish a professional standard for acting in health promotion.
Considering the complexity and the existing gaps in training for the development of skills in the health scenario, European researchers developed the Developing Competencies and Professional Standards for Health Promotion Capacity Building also known as Competencies Health Promotion Project (CompHP) (4)(5)(6) . This document contemplates a minimum set of knowledge, skills and attitudes that constitute the common and essential basis for all health promotion functions, providing subsidies to guide the training of the health workforce (6) .
It should be noted that the CompHP, although established based on the reality of public health in Europe, points out possibilities for reorienting professional performance in the field of health promotion, to overcome the predominantly curative and disarticulated approach to health practices. In this sense, it is in line with the assumptions of policies that induce health education in the Ministries of Health and Education (7)(8) within the scope of SUS.
In this light, the scientific literature emphasizes the need to develop research that indicates the necessary adaptations and specificities for the reorientation of health education (5,(9)(10)(11)(12) . Understanding how the skills for health promotion are manifested in professional training is unique, as well as recognizing how they are included in the pedagogical projects of the courses and mobilized by their professors. These reflections were constituted as central issues in the present study.

OBJECTIVES
To recognize the competencies for health promotion and their magnitude of expression in undergraduate health education based on the analysis of the pedagogical projects of the courses and from the teaching perspective.

Ethical aspects
This study is part of a multicenter study, entitled "Studies on Health Promotion in Educational and Work Environments", approved by the Research Ethics Committee. All prerogatives of Resolution n. 466/12 on ethical care in research involving human beings were followed (13) .

Theoretical Framework
The CompHP was adopted as a theoretical framework for conducting the study. This covers a set of 46 competencies necessary to create effective actions in health promotion, organized in nine dimensions, namely the possibility of changes, health advocacy, partnership, communication, leadership, diagnosis, planning, implementation and evaluation and research (6) .

Type of study
Descriptive, documentary and field research, of a study case type, with a mixed approach (14) . The sequential exploratory WHICHquan execution was chosen, in which quantitative data complement the qualitative data collected and initially analyzed (15) . This way, the communication of results followed the guidelines of the Consolidated Criteria for Reporting Qualitative Research (COREQ) (16) .

Study setting
It was defined as a research field a public university located in the southern region of the state of Ceará, due to its strategic role for the region in professional training and knowledge production. It offers 16 undergraduate courses, three of them in the health area: Biological Sciences, Nursing and Physical Education. The last two were selected to compose this study, due to the nature of the training of these professionals, which requires students to have skills to work in the field of public/collective health.
The undergraduate nursing course, established in 1998, is a bachelor's degree and is divided into ten semesters, making a total workload of 4,485 hours. The Physical Education degree course, established in 2013, has a workload of 3,620 hours divided into eight semesters. Both courses foster professional competencies according to their respective NC, and the training takes place based on the teaching-research-extension tripod, with semester entry.

Data source
To achieve the object of study, three data sources were chosen: the documentary data, subsidized by reading the Pedagogical Projects (PP) of the Nursing and Physical Education courses, were materialized as instruments that guide their practices, being, therefore, essential to consider them.
The speeches of 31 professors from the referred university were also analyzed, given their performance in the training of health professionals. For that, the following inclusion criteria were chosen: to be a professor in Nursing and Physical Education courses and to exercise the teaching role for at least one year. Professors absent from their activities for any reason did not participate.
The Health Promotion Competency Matrix (CompEPS) (17) was also used. Based on the CompHP framework, CompEPS was validated and deals with the essential skills to be developed by health-promoting professionals in the Brazilian context.

Data collection and organization
The operationalization of data collection took place from July to October 2018.
After the authorization and availability of PP by the secretariats of the respective courses, the reading and data collection stage began, guided by an instrument of our elaboration, contemplating health promotion skills. In this process, attention was given to the objectives, the theoretical-methodological framework, the curricular matrix, and the programmatic content, recognizing the approximations and distances with the adopted theoretical framework.
The interviews with the 31 professors, 22 professors from the Nursing course and nine from the Physical Education course, were carried out at the university itself, in a private location, with only the presence of a researcher and the interviewee. The interview was guided by open questions that contemplated the skills considered essential by the subjects to carry out health promotion actions and curricular components that favor their development. The speeches were recorded in digital media, lasted an average of 30 minutes, and were ended when the theoretical saturation in the collected content was recognized.
To ensure methodological rigor during the interview, at the end of the statements, the information was reproduced by the researcher so that the professors could refute, add information not yet said or confirm the idea expressed. In the speech fragments presented in this study, the participants were identified by an alphanumeric system, following the sequence of data collection (P01, P02...), to preserve their confidentiality and identity.
After the interviews, the CompEPS Matrix was applied to the participants, on the five-point Likert scale, suggesting the level of relevance attributed by the professor to the essential skills in health promotion in the training process in which he/she was inserted.
This threesome of information aimed to ensure a deeper understanding of the phenomenon under study.

Data analysis
Thematic Analysis was used, guided by the theoretical contribution of the CompHP for organization and documentary analysis and of the contents of the interviews with the professors, from the perspective of analytical categories, treating each dimension as a category (18) .
The CompEPS Matrix data were processed using the SPSS version 23.0 for Windows® program and subsequently subjected to descriptive statistical treatment, with the calculation of mode and interquartile range. A calculation was performed to establish the mean mode of each competency designated by the dimension to represent the Magnitude of Global Expression (MGE), portraying the importance attributed by the professors to the analyzed dimension.

RESULTS
As for the characterization of the 31 professors participating, they were mostly female (21), with an average age of 38 years, ranging from 25 the minimum age and 62 the maximum. Regarding teaching time, a minimum period of one year and a maximum period of 25 years were obtained, making an average of 10 years and 7 months in teaching.
Regarding the profile of the subjects they teach at graduation, most professors (20) are based in theoretical-practical subjects, 12 teach theoretical subjects and 10 practical subjects, which take place within the scope of public health services. It should be noted that some professors teach more than one subject.
Considering the competency dimensions of CompHP, this section brings the main findings on health promotion competency dimensions expressed in the training of Nursing and Physical Education, identified from the analysis of the PP, the interviews and the MGE, presented in Chart 1.

POSSIBILITY OF CHANGES
Professional action to enable individuals, groups, communities or organizations to build capability for response in health promotion, and thus improve and reduce health inequities (2)

PP* Nursing PP* Physical Education Interviews
"Promote healthy lifestyles, reconciling the needs of both clients/patients and their community, acting as an agent of social transformation. "

PARTNERSHIP
It consists of working in collaboration with areas of knowledge/disciplines, sectors and partners to increase the impact and sustainability of Health Promotion actions (2)

PP* Nursing PP* Physical Education Interviews
"Each professional must ensure that their practice is carried out in an integrated and continuous manner with the other instances of the health system. " "Participate, advise, coordinate, lead and manage multidisciplinary teams of discussion, define and implement public and institutional policies in the health fields (...)" "Promote partnerships with the responsible agency to be also helping in that health promotion process, partnerships." (P02) MGE**: 4.75 -IQR***: 1.00

COMMUNICATION
It manifests itself when communicating health promotion actions effectively, using appropriate techniques and technologies for different audiences (2) PP* Nursing PP* Physical Education Interviews

PLANNING
Comprises actions to mobilize individuals to develop health promotion goals and objectives that can be measured, based on the diagnosis of needs and potential in partnership with social actors/partners (2)

PP* Nursing PP* Physical Education Interviews
"Responding to regional health specificities through strategically planned interventions. " "Coordinate teamwork, select, prioritize and analyze problems to build intervention plans. " "Planning, implementation and evaluation of professional intervention programs. " "Competencies have to be in the planning issue." "I think the professional has to be an educator, has to be a manager, know how to plan." (P21) MGE**: 5.0 -IQR***: 1.00 To be continued In the PP of the Physical Education course, except for the possibility of changes, the presence of the dimensions of competencies in health promotion was recognized in the documents guiding the training of the analyzed courses and in the speeches of the professors of these courses.
Besides the areas of competency, it was possible to identify that the PP of the courses studied are also in line with the ethical values and basic knowledge covered in CompHP. This is evident when they signal the importance of considering the political, economic, social, cultural, environmental, behavioral and biological determinants of individuals for the promotion of health and well-being, when they recognize the beliefs and preferences expressed by individuals and as they foster the need for continuous reflection on behavior and professional practice to identify improvements in their performance.
The MGE assigned to each dimension reveals that professors recognize all dimensions of competency in health promotion as extremely important to health training (mode ≥4.5).

DISCUSSION
Even though all other competency dimensions have been found, the failure to identify the possibility of changes in the Physical Education PP provokes reflections on the importance of the official document that rules the course to highlight it, so that it guides the professor and sensitizes him/her to provide the opportunity for the development of this competency during the student's training. However, the expressiveness in the professor's speech and the magnitude of importance given by them to this attribute allows saying that the professors are sensitive to this need, evidencing an advance towards the competencies for health promotion.
The possibility of changes dimension in undergraduate nursing shows the development of skills based on critical reflection to act promoting modifications and improvements in different social contexts, since it provides a theoretical and practical basis for the development of health actions. It is worth mentioning that these actions are guided by the educational and health principles from relevant policies and documents (19) .
The possibility of changes begins with the redirection of training processes, through political and institutional advances in health promotion, with the implementation of initiatives in the field of public and collective health and (re)formulation of public policies that induce professional training based on skills (2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) . It is observed in this, as in other studies (20)(21) , that health training, especially in the context of Nursing, is in the process of reorientation and has stimulated the development and adoption of its professional role as social actors and agents of social transformation.
Aware that the changes to improve the health scenario start from democratization and promotion of access to services and goods to its users, the health advocacy dimension also presents itself as an instrument for the defense of the universal right to health, promptly articulating itself the possibility of changes (22) .
Promoting health requires much broader actions than simply individual ones. It involves a set of aspects related to social determinants and conditions that interfere in the health of the individual and the community (23) . It is not just a matter of preventing illnesses, treating a disease, or educating in health, but it comprises the development of new models of health care that support actions aimed at the health of the community. In this context, it is reaffirmed, therefore, the relevance of health promotion actions, through the involvement of citizens and, together with them, in the guarantee and effectiveness of their health rights.

IMPLEMENTATION
It is based on the implementation of effective, efficient, culturally sensitive and ethical health promotion actions, in partnership with social actors/ partners (2)

PP* Nursing PP* Physical Education Interviews
"Plan and implement an education and health promotion program, considering the specificities of different social groups and the different processes of life, health, work and illness. " "Analyze reflexively to intervene ethically in your daily professional situations. " "Planning, implementation and evaluation of professional intervention programs. " The idea of claiming with and in favor of the population shows participation and/or social control, as stated in the principles and guidelines of the SUS and the Política Nacional de Atenção Básica -PNAB (National Primary Care Policy) (24)(25) . This approach to public health policies, their foundations and precepts, potentiates the development of health advocacy through the teachingservice-community integration, according to the proposals of the analyzed training processes.
The proposal to advocate in health, within the scope of integration with health services and with the collectivities to which they belong, is based on the principle that the mobilization of different sectors and actors is necessary for the effectiveness of comprehensiveness and universality in health.In this sense, the partnership, which is also one of the guidelines of the Política Nacional de Promoção da Saúde -PNPS (National Health Promotion Policy), emerges as an essential competency, whose main purpose is to encourage intersectoral actions that enable the comprehensive development of health promotion actions (26) .
In this context, urge the challenge for training processes to advance in the establishment of intra and intersectoral combinations, under the logic of incorporation and collaboration of the work of several other sectors (educational, cultural, economic, political, among others) to health. Also emerges the challenge of implementing multi and interprofessional work to meet the most emerging needs of the individual and collective population.
Establishing partnerships focused on health promotion also presupposes the exchange of knowledge between the different training processes and different areas of knowledge. From this perspective, these exchanges must be effective and significant in knowledge and practices, driven by dialogue and the valorization of different knowledge (27) so that, together, they work towards a common goal (28) .
Considering the complexity of working in intersectoral and interdisciplinary networks that are necessary for the health field, the relationships of partnerships are consolidated based on good communication practices between the various actors that are part of this context, including users and professionals.
Communication manifested itself as a dimension of competencies to be developed during professional training, encompassing verbal and non-verbal aspects, and enabling the implementation and use of information and communication technologies as a strategy to assist this process. Such aspects are consistent with the NC of the courses under study.
Vocational training should enable the development of permanent general skills and abilities of communication and education that include the mastery of information and communication technologies (3) .
Although communication is recognized as essential for professional training, some inconsistent aspects between the desired and the offered were identified in the analyzed PP, such as the acknowledgment of the importance of mastering a foreign language, however without offering this type of subject in the curriculum. Another inconsistency was the absence of a discipline of Brazilian Sign Language, not considering the communicative process with hearing impaired, for example, which goes against the principles of integrality and universality of health care.
The meaning of the word communicate refers to "put in common", for this purpose, the act of communicating in the health field calls for the appreciation of the understanding of life contexts and meanings of illness from the user's perspective. Thus, the professional must be open to welcome the other and develop their communication skills (29) .
In this light, the relevance of establishing good communication relationships between professors-students and/or professionalpatient/user is highlighted, since, when established through a therapeutic relationship, they are favorable for decision making in SUS and development of health promotion actions, based on dialogue, qualified listening, as well as non-verbal manifestations. The main objective must be based on the transmission of information in an effective way, making the user active and autonomous in health decisions that favor self-care (29) .
In general, health care actions are based on exchanges introduced during the communication process, which should favor a horizontal relationship between the professional and the service user. This makes it easier to reach the goals set for improving the population's quality of life and health.
Characterized as the ability to coordinate an individual or group to influence it positively, the leadership competency was also highlighted in the studied reality, manifesting itself in the encouragement to exercise decision-making, proactivity, the leadership of the work in team and problem solving, evidenced in the statements and documents analyzed (30) .
Leadership enables professionals to develop their role with a focus on transforming ideas, intentions, goals and, consequently, results, balancing the work environment, actively participating in the planning processes and encouraging the leadership skills of other professionals (31) . Thus, it is possible that, together with the users of the health service, they can transform the reality in which they are inserted, thus, in line with the NC.
In this sense, the success of the professional who exercises leadership occurs through observation and attention to trends, perceptions and needs of users of the health service. It also depends on a permanent evaluation of the implemented actions, which can be cases of success or failure, but which make the professional more and more resistant to the challenges they are faced with (32) .
Concerning the dimensions of diagnosis, planning, implementation, evaluation, and research there is an interconnection between them, manifesting themselves as complementary steps in a sequential and cyclic process (33) . Thus, one cannot advance successfully in one of the dimensions without the full growth of another.
The diagnostic dimension is foreseen in the training of undergraduate students in both courses. Some of the main aspects related to it are the need to analyze the problems of society, recognize the epidemiological profiles of populations, consider the interests, and needs of students, among others. The NC describe as desirable that the professional has the ability and attitude to diagnose people's interests, expectations and needs, so that they can solve health problems, encompassing this dimension (3,30) .
It is important to note that health diagnosis is not only about health problems and needs, but it is also possible to diagnose potentialities. These can be social actors or other services and devices that favor a better relationship between service-community and help to promote a better quality of life and health. Thus, when the professional has the diagnostic ability, he/she can develop a more critical view and, based on the identification of situations that enhance or hinder the reach of health, he/she adds planning to the work. It is worth mentioning that planning is the relevant dimension for the construction of proposals that solve the demands found in a good diagnosis.
The planning guides health work, as it allows professionals to guide their actions based on the goals and objectives they intend to achieve. Therefore, an expanded situational analysis is necessary, to identify the epidemiological, territorial profile, raise own resources, make a subjective analysis and map the relationships between service and users (34) .
This aspect allows us to highlight the importance of planning as a necessary competency for carrying out health actions. However, it is worth noting that, just as it is necessary to diagnose to plan, it is essential that this planning precedes the action, that is, the implementation of planned care.
The implementation dimension, as indicated in the PP, is based on the development of actions for health promotion and education, which are presented as facilitating strategies in the processes of changes in lifestyles, work and, consequently, in the health-disease process, through critical and ethical analysis of reality, considering the particularities and needs of those involved. It is the effectiveness of health promotion actions in acts, in the territories, with individuals, their collectivities and their realities.
Thus, the implementation of health promotion actions must be incorporated into the realities of health services and aligned with the desired care model, especially in the routine of primary care services. This reaffirms the need to integrate the academy and health services in professional training.
According to the data presented, the competency of evaluation and research is based on the judgment of the actions taken, the results of which will serve as a basis for decision making. The term evaluation refers to an understanding of something in which a judgment needs to be made -an intervention or any other aspect. For this, it is necessary to make a careful analysis of what was planned, executed, implemented and achieved.
In this sense, health assessment aims to support decisionmaking processes, subsidizing the reorientation of actions and services, and measuring the impact of the actions implemented on the population's health and well-being, materializing as a possibility and a necessity (35) . From this perspective, health assessment should be understood as formative, capable of promoting improvements, support and encouragement for positive transformations in the activities and actions implemented, and not as punitive, as has sometimes been understood (36) .
This evaluation process must be intrinsically linked to research, anchoring itself in evidence-based practice and strengthening it. Therefore, there is an urgent need to reduce the gap between conducting research and health services, in a real and effective process of teaching-service-community integration that ensures the development of skills not only by students and professors involved in the process, but also by professionals and the community as part of this relationship web.
Such perspective starts from the need to face the consolidation of the concept that research is an exclusive or priority job of the university, ensuring the involvement of professionals in the construction of scientific knowledge in health (37) .

Study Limitation
It is recognized as a limitation the failure to capture the object under practical aspects, along with formative moments such as classes and internships, as well as under the student perspective, these being possibilities for the development of future work.

Contributions to the area
Propose reflections on the necessary updating of undergraduate health courses to provide professional training concerning the development of skills for health promotion. It is also expected that this study will contribute, through a local reality, to foster evaluation practices, through the union of current trends, social and ideological changes, and to promote changes that (re)guide the training processes in health.

FINAL CONSIDERATIONS
The dimensions of competencies for health promotion are present in the training processes of Nursing and Physical Education courses, which denotes training aligned with health promotion and relevant to professional performance in SUS. This indicator represents an advance in the organization of pedagogical practices, since it is in line with national and international debates essential to the implementation of health practices, overcoming challenges and contributing to the training of professionals capable of acting with quality.
However, it is recognized that only the contemplation of these areas of competency in the formative documents and the speeches of the professors involved in the formative processes does not ensure their full development. These dimensions must transcend the theoretical-normative aspect of training and reach the spaces for debate and formative practice. It is also supported the need to develop the completeness of the presented dimensions, since there is a logical and dependent relationship between them, important to the work of the health promoter.

FUNDING
The present work was carried out with the support of the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (FUNCAP) (Ceará Foundation for Support to Scientific and Technological Development).