Professional competency for elder care: perception among professors, nursing students, and nurses.

OBJECTIVE
to know the perception of nurses, undergraduate students, and professors about the competencies for professional nurses in elder care.


METHODS
this is a qualitative analytical study developed with six professors, four nurses, and 12 nursing students. Data were collected through semi-structured interviews and analyzed using Fiorin's Discourse technique, with support from the MAXQDA software.


RESULTS
the competencies identified included knowledge of theories and general concepts of gerontology, communication, listening, leadership, teamwork, proactivity, respect, and empathy.


FINAL CONSIDERATIONS
knowing the competencies contributes to understanding the aging process and qualifying nurses for elder care.


INTRODUCTION
Increase in life expectancy has generated changes related to the demographic profile of the elderly population. Worldwide, this age group grows approximately 3% per year, with estimates that they will represent 2.1 billion people in 2050. In Brazil, this growth will occur even more rapidly, considering that they correspond to 13% of the population and, in 2050, they will represent 29.3% (1) .
In this context, attention to elderly people stands out, which has specificities arising from the heterogeneity of aging and the demand for adequate management due to its complexity (2) . One of the challenges encountered is the ability to train health professionals, including nurses, with technical and political competency to work in care aimed at the elderly population (3) .
Nursing training must be in accordance with the Brazilian National Health Policy for Elderly People (PNSPI -Política Nacional de Saúde da Pessoa Idosa) recommendations. This covers the need to include subjects in the curricula of Higher Education Institutions (HEIs) that address aging, in order to ensure health promotion, disease prevention and health rehabilitation for people in the elderly age group (4) .
The institutions responsible for the training of nurses must develop competent professionals for elder care, focusing on the biopsychosocial particularities of this age group (5) . Such training must be in line with the Brazilian National Curricular Guidelines (DNC -Diretrizes Nacionais Currilares) (6) , whose objective is to organize and guide curricula that collaborate for a health professional training with a humanistic, critical and reflective view.
Moreover, DNC (6) also recommend that the training of health professionals is focused on building competencies. Competency is understood as a set of knowledge, skills, and attitudes (7) . These competencies are associated with knowledge, including knowing how to know (knowledge), knowing how to do (skills), knowing how to live (attitudes) and knowing how to be, which are essential for solving problems (8) .
Although there is a considerable amount of research on the competencies aimed at nurses, there is a shortage with regard to competencies for elder care. In this sense, there is a need to know which competencies in caring for elderly people by those involved in the process of training nurses, since, from that, strategies can be developed to build a curriculum focused on these competencies.
It is expected that the construction of a competency profile will collaborate in the structuring of curricular strategies, favoring a qualified training of nurses, aimed at providing care to the elderly population. From this context, the question is: what are the competencies needed for elder care?

OBJECTIVE
To know the perception of nurses, undergraduate students, and professors about the competencies for professional nurses in elder care.

Ethical aspects
This study was approved by the Standing Committee on Ethics in Research with Human Beings at Universidade Estadual de Maringá. All subjects were informed about the research and signed the Informed Consent Form.

Theoretical-methodological framework
This is a qualitative analytical study, which used the four necessary knowledge for the education of the future. Competency must move knowledge about an action through the relationship established with others within the work. These knowledges are linked to the four pillars of education, which include those aimed at knowledge, understood as knowing how to know, competencies, how to know how to do and attitudes, how to know how to live together and how to be (8)(9) .
Knowing how to know, in addition to obtaining knowledge, is related to the mental process command of perception, memory, judgment, and/or reasoning. The learning cycle must undergo constant changes, carried out over the experiences acquired by subjects, in which education is able to provide the foundation that allows for learning throughout life (8) .
Know-how is not only related to the organization for carrying out an activity. It includes the need to be coupled with technical preparation and the competencies aimed at teamwork, initiative and decision making in relation to different circumstances existing within professional practice (8) .
Knowing how to live together aims to educate about differences, also defending the similarity and interdependence awareness existing among the population. Knowing how to be is related to the social commitment made by workers amidst the facts that occurred in the environment in which they are inserted, being able to transform this reality (8) .

Type of study and methodological procedures
This is a qualitative analytical study, originated from a master's dissertation. The study was developed according to the Consolidated criteria for reporting qualitative research (COREQ).

Study setting
The present study was carried out in four settings: in the department of nursing of a public HEI in northwestern Paraná and in practice settings of the gerontogeriatric nursing course, which include a Basic Health Unit and two Nursing Homes.

Data source
The research subjects were 12 students of the fourth year of graduation and graduates in 2018, considering that the course "gerontogeriatric nursing" was implemented in 2017 in the HEI under study, being taught to students of the third year of graduation. Six professors, among them the head and coordination of a department of nursing, participated in the elaboration of the curricular matrix that included the course. Also included in the research were four nurses who work in the fields of compulsory internship in the subject, who develop activities in practice and support the teaching of undergraduates.
The selection of participants was made by convenience, and the number of interviews followed the criterion of information of Professional competencies for elder care: perception among professors, nursing students, and nurses Ferreira R, Derhun FM, Carreira L, Baldissera VDA, Radovanovic CAT, Mariano PP.
saturation, that is, when the research problem was already adequately clarified and there were no new elements reported by the participants. The total number of participants (undergraduates, professors and professionals) corresponded to all subjects approached to carry out the research.

Data collection and organization
Data collection was guided by a semi-structured instrument consisting of two parts: one addressing sociodemographic characteristics and the other with open questions about the competencies for professional nurses in elder care. The instrument underwent apparent and content assessment by three doctors, the first in the field of gerontogeriatrics, the second in the area of nursing education and the third in the area of adult health.
At first, an email was sent to the respective professors inviting them to join the group of judges in charge of adapting the script of questions that were used in the master's research. After acceptance, the instrument was sent with an objective assessment of all questions. The correction occurred in two moments until both professors rated the instrument as highly satisfactory.
The data collection instrument presented three guiding questions, each referring to a category of participant (undergraduate, professor and nurse). In relation to the undergraduate student, the interview was conducted with the following question: what knowledge, competencies and attitudes are necessary to develop internship practices in elderly people's health? As for the professor, it was asked: what knowledge, competencies and attitudes do you consider necessary to be developed in the training of nursing students before the course of elderly health proposed in the curriculum? As for nurses, the interview was based on the question: what knowledge, competencies and attitudes towards elderly people's health are necessary to develop elder care in their work context?
The interviews were conducted by the main researcher. Before the start of data collection, the referred institution provided the researcher with a list containing the names of enrolled and alumni, names of professors and telephone number. In relation to nurses, first contact was made with the referred places of work, so that they could provide the private phone number. In this way, students, professors and nurses were approached individually via telephone, about availability/interest in participating in the research, and, through verbal acceptance, the interviews were conducted individually on the university premises, in the work fields or in interviewee's own residence.
Data collection was carried out in March and April 2019. The audios were recorded, transcribed in full, and analyzed. The interviews lasted an average of eight minutes.

Data analysis
For the textual organization and data coding, the MAXQDA software, version 2018 was used. MAXQDA software is a Windows operating system, which assists with the analysis of qualitative data, used as research instruments. This software incorporates documents of different formats (DOC, PDF), images (JPG, GIF), texts, focus group interviews, online questionnaires, internet pages, images and audio and video files, in order to encode them for analyze (10) .
For the present study, the interviews carried out were transcribed in the Microsoft Word 2010 program, then saved in PDF. Then, the document was incorporated into the MAXQDA software, in which the data was coded by creating a code list that included the categories of knowledge: knowledge, competencies and attitudes. The categories created were fed according to the reading and selection of excerpts from the interviews relevant to the research objective.
The empirical material derived from the codification was analyzed using Fiorin's Discourse Data Analysis Technique, which understands discourse as a social position, whose ideological aspects are consolidated in language, needing to be analyzed. In this sense, "discourse analysis goes, as it studies the discursive elements, showing, by inference, the world view of the subjects enrolled in the discourse" (11) . Analysis allowed identifying necessary competencies for nurses' practice in caring for elderly people, which were presented in three categories: knowledge, competencies, and attitudes.
The construction of a competency profile for elder care involved the participation of different subjects involved in teaching and nursing care processes. Participants were identified with letters S, P and N referring to student, professor and nurse, respectively, and listed according to the order of the interviews.

RESULTS
Thus, 22 participants were interviewed. Regarding the participants, the majority were nursing students (54.5%), aged 20 to 30 years (68.1%), with females being more prevalent (90.9%). Time working as a professor ranged from 10 to 20 years (50%), and time working as a nurse was 5 to 15 years (80%).
Respecting the theoretical framework, the analyzes started from the categories of knowledge, knowledge, competency, and attitude, in which they presented the following competencies, according to participants' statements:

Knowledge
Knowledge about gerontology theories/concepts was identified as necessary, covering knowledge about the physiological and pathological changes of aging, elder frailty, aspects of functionality that allow the classification of elderly people in different profiles and, consequently, to intervene more specifically.
We need to know about screening for frailty in elderly people. So, when the student comes to do a course like this, he must put these concepts together. When I have a frail elderly person and a robust elderly person, I have both with different needs and then the concept of equity will guarantee me how to take care of each type of elderly person.

Competencies
Communication was identified as an effective competency in the interaction between nurses and elderly people. Qualified of Professional competencies for elder care: perception among professors, nursing students, and nurses Ferreira R, Derhun FM, Carreira L, Baldissera VDA, Radovanovic CAT, Mariano PP.
listening proved to be an important competency in order to allow students to be able to listen to elderly people. Leadership, both to stimulate their team and elderly people, was placed as a necessary competency to act in the different settings that serve elderly people population. And, finally, the competency of working in a team was mentioned, either with nursing professionals or with others in the health field to carry out a task aimed at elder care.

Attitude
Proactivity was identified as a necessary competency for nurses to take initiatives before different situations in the work environment. Respect, a competency consisting of representative behaviors and actions of dignity that consider the particularities of each person and empathy, such as the ability to put oneself in the other's place, allow nurses to assist elderly people respecting their limitations, desires and desires.

In relation to attitudes, what I expect from the student is that he will be proactive in relation to care for elderly people. May he be proactive in assessing elderly people and doing Single Therapeutic Projects. (P-4)
Attitude to encourage elderly people to participate in the stretching and walking groups. Competency is related to a practical application within the work environment, which allows nurses to solve everyday situations, with the objective of obtaining desired results for improving elderly people's quality of life.

DISCUSSION
Aging does not only bring changes that negatively modify life, but it is also related to the projection of a positive future, which goes according to the concept of healthy aging, indicated by the World Health Organization (WHO), being a "process of development and maintenance of functional capacity that allows for well-being in old age" (12)(13) . Therefore, it is necessary to carry out care strategies that enable the building of competencies, including by nurses, so that elderly people can live with quality (13) .
In this regard, with regard to general competencies, health professionals must be able to establish actions for the prevention, promotion, protection and rehabilitation of the population's health. These professionals must perform quality services following the principles of ethics/bioethics, being able to not only perform the technique, but to solve health problems both individually and collectively (14) .
In the context of nursing care, professional nurses need to develop competencies to care for individuals at all stages of life (14) . Thus, in relation to assistance to elderly people, the present study identified the following competencies related to the categories of knowledge (7)(8) : knowledge about theories and general concepts of gerontology, related to "knowing how to know" (knowledge); communication, listening, leadership and teamwork, contemplating the competency category that refers to "knowing how to do"; proactivity, respect and empathy, which encompass the attitude, that is, the "knowing how to live and knowing how to be".
With regard to competencies aimed at knowledge, an elderly health course is important for undergraduate nursing that includes, in its teaching plan, contents that allow identifying physiological changes related to multiple body systems and anatomical changes that result in changes related to reflexes, balance, strength, reaction time and reasoning (15) , as well as psychological changes, which end up reflecting on the appearance and prognosis of diseases, especially those of a chronic character, in elderly people (16) .
The knowledge competency covered the physiological and pathological changes of aging, frailty and aspects of elderly people's functionality. This knowledge is related to general theories and concepts of gerontology, which allow nursing professionals to identify and understand the particularities of the aging process as well as elderly people's specific needs.
This knowledge must also include the health-disease process, aimed at assistance diagnosis, planning and assessment at the levels of prevention, promotion, recovery and rehabilitation of elderly people. Therefore, it is important to combine basic science with specific knowledge for elderly people, which include senescence, senility, autonomy, dependence, vulnerability and stratification of frailty among elderly people (17) .
One way of working with such content is through Multidimensional Assessment of Elderly People, in which issues related to individuals' biopsychosocial aspects are identified. This diagnosis makes it possible to detect the disabilities that are linked to independence and autonomy, focused on Activities of Daily Living, as well as implications related to the functional system, such as cognition, mood, mobility and communication, in order to outline an intervention plan appropriate to clinical-functional condition of elderly people (18) .
The training of nursing professionals in the context of gerontology should promote the development of competencies that enhance the performance of nurses. Such training must be in line with DNC. Within DCN, the undergraduate nursing course 7 of Professional competencies for elder care: perception among professors, nursing students, and nurses Ferreira R, Derhun FM, Carreira L, Baldissera VDA, Radovanovic CAT, Mariano PP. must comply with SUS (Sistema Único de Saúde -Unified Health System) principles, taking care of care and comprehensiveness, of management and management, of education, of nursing research, of professionalization and class organization, acting in assistance and in the development of competencies, which are: "health care, decision making, communication, leadership, administration and management and permanent education" (14)(15)(16)(17)(18)(19) . Among these competencies presented by DCN, communication stands out, also identified by the present study as a necessary competency for nurses in elder care. For nursing, communication needs to be inserted in the actions of guidance, support and information, which collaborate for the know-how within the service and, above all, in the humanization of care (20) .
Allied to communication, listening was also presented by professors as a competency. Through the method of capturing, interpreting information and complying with practices, which require impartiality and neutrality, listening is presented as a primary competency for the effectiveness of the communication process, allowing the approach of aspects related to individuals' emotional, cognition, and behavior (21) , thus enhancing the assistance of professionals.
Introducing students in this perspective collaborates so that they have a commitment and a cautious look at the gestures presented by patients and are able to search for essential information to the affective, emotional field, desires, desires, tensions, anxieties and fears, presented by each individual (22) .
Leadership, also mentioned by DCN, was another competency presented by the professors of this study. This is marked by creativity, innovation and vision (23) . As nurses who work for the quality of care, they are considered by their staff and patients as professional references (24) . Leadership in nursing consists of making the practice of actions aimed at service management accountable, with a view to team performance and problemsolving aimed at patients (25)(26) .
Another competency related to competencies is teamwork, considered satisfactory when the different subjects involved in health care are allied to effectively carry out the actions proposed within their work environment, to better serve the current population (27) . For professors, team work during elder care should be carried out collaboratively, at all levels of care, due to the needs of attention that this population presents due to the physiological and pathological processes that involve aging. The joint work between the nursing team and other health professionals is a primary tool for the promotion of comprehensive care for elderly people.
In relation to the competencies focused on attitudes, proactivity is identified as a performance, in which workers seek changes in their work environment and solve problems, tending to benefit the organization (28) . In this context, for elderly people's health, proactive action must go beyond the disease, it must incorporate strategies that analyze multi and interdisciplinarity, and the nonfragmentation of processes, with a view towards the continuous advancement of practices (29) .
The DCN of the Nursing Graduation Course presents decisionmaking as a competency, although it was not mentioned by the study participants. However, the proactivity and knowledge of theories and concepts of gerontology, competencies related to the areas of knowledge, attitude and knowledge, respectively, were identified by professors and undergraduates as necessary competencies regarding nursing care for elderly people. Thus, it is possible to relate them to decision-making, since, for professionals to be able to decide before an adversity in their practice, they need to have sufficient knowledge and action potential to think and act in advance, in order to avoid or minimize future problems or evolution of the problem already identified.
Still in relation to competencies focused on attitude, the students mentioned respect as a fundamental element for the relationship between nurses and elderly people. According to the Senior Citizen Statute, "the State and society must guarantee to an elderly person freedom, respect and dignity, as a human person and subject to civil, political, individual and social rights, guaranteed in the Constitution and in the laws". In this sense, respect is related to the act of not violating individuals' physical, psychological and moral integrity, preserving their image, identity, autonomy, values, ideas, and beliefs (30) .
Allied to respect, empathy was also presented as an attitude that contributes to the nurse-elderly relationship, covering aspects of affection among those involved. Developing this competency is based on respect and reciprocity, which allows resolutive care, self-knowledge, self-care, in addition to reducing stress and anxiety, which allows control between individuals and the environment (31) . Thus, it allows nurses to understand elderly people's emotional states and undertake reflections and/or discussions before the situations presented.
Developing competencies for elder care can be enhanced through the use of appropriate teaching-learning methodologies. Pedagogical practices should lead to modifying, ethical and reflective actions, benefiting undergraduate students in a way that leads them to reflect and participate in innovative practices present in the academic setting prompted by learning to learn, learning to be, learning to do and learn to live together (32) .
HEIs, as well as private institutions, have an important role in relation to the formation of the profile of nurses. These should provide a curricular organization that considers the insertion of pedagogical projects that guarantee professional qualification before the current demands of the context to which this professional will be inserted (33) .
Thinking about the expressive increase of the elderly population, several adjustments are necessary in the process of training nurses. This training must also be in line with what PNSPI recommends, which highlights the need for insertion of courses in the curricula of HEIs that address aging, with the aim of valuing it and propagating health promotion measures, disease prevention and health rehabilitation for elderly people (4) .

Study limitations
Concerning the limitations, the fact that the research was carried out only with nursing students, professors and nurses working in the fields of practical classes of a single HEI stands out, being, therefore, a cut of a context, which does not allow generalization of data. It is recommended to expand the study to other educational institutions, with a view to expanded analysis and/or comparisons, in order to contribute to identifying gaps in nursing training regarding competencies for elder care.

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Professional competencies for elder care: perception among professors, nursing students, and nurses Ferreira R, Derhun FM, Carreira L, Baldissera VDA, Radovanovic CAT, Mariano PP.

Contributions to nursing
Knowing these competencies allows understanding the role of nurses in elder care. In this sense, it contributes to the reflection of nursing behaviors and actions so that care encompasses the particularities of this age group. Moreover, it contributes to the professors involved in the teaching-learning process to improve the training process aimed at elderly people's health, through the construction, development and assessment of the course's pedagogical projects.
Furthermore, this study contributes to encourage reflection on the training of nurses, providing subsidies for teaching, nursing practice, and public health. For teaching, it is related to the preparation of professionals in undergraduate courses, with the objective of obtaining knowledge that supports the understanding of the aging process in a comprehensive way. This will allow the exercise of attitudes and competencies within practices, referring to health-disease and elder care, which will surely be used in the future professional practice of these individuals.

FINAL CONSIDERATIONS
Nursing training needs to be adapted to changing the demographic profile of the population, thus bringing the context of teaching and practice closer together. Elderly people's health is broad and complex, since it addresses specific aspects regarding changes in the subject's health-disease process, as well as their capacities, needs and expectations. Therefore, the future nurse must be inserted in the context of gerontology at the beginning of their training, in order to receive a specific education regarding assistance to elderly people, in which necessary knowledge, competencies and attitudes for such care are developed.
Knowing this profile of professional nurses' competencies for elder care expresses the need to qualify nursing actions considering the particularities and needs of this population. For nurses, these competencies can represent resources to understand the aging process in its conceptual, physical, emotional and social aspects, enabling developing actions consistent with the reality that an elderly person finds.