Nursing competencies in promoting the health of individuals with chronic diseases

Objective: to identify nurse’s competencies related to health promotion of individuals with chronic cardiac disease, in the light of the Galway consensus. Method: integrative literature review was conducted to search for studies published between 2010 and 2014 in the databases LILACS, BDENF, IBECS; and PubMed in February 2015. The 21 included studies were analyzed according to the eight domains of competence: Catalyzing change, Leadership, Evaluation, Planning, Implementation, Assessment, Advocacy and Partnerships. Results: all domains of competence were included in the nursing interventions in health promotion of chronic cardiac patients, and the Planning and Evaluation were the most evident competences. Conclusion: the results of this research highlighted the nurse as an agent capable of operating care management, in order to improve coordination of the latter with work and education and, thus, the health care of the population. Descriptors: Chronic Disease; Heart Diseases; Professional Competence; Nursing; Health promotion. RESUMO Objetivo: identifi car as competências do enfermeiro relacionadas à promoção da saúde de indivíduos com cardiopatas crônicas, à luz do Consenso de Galway. Método: revisão integrativa da literatura, com busca de artigos publicados entre os anos de 2010 e 2014, nas bases de dados LILACS, BDENF, IBECS; e no portal PubMed, em fevereiro de 2015. Os 21 artigos selecionados foram analisados de acordo com os oito domínios de competências: Catalisar mudanças, Liderança, Avaliação das necessidades, Planejamento, Implementação, Avaliação do impacto, Defesa de direitos e Parcerias. Resultados: todos os domínios de competências foram contemplados nas intervenções do enfermeiro na promoção da saúde de cardiopatas crônicos, sendo o Planejamento e a Avaliação os mais evidenciados. Conclusão: os resultados desta pesquisa destacaram o enfermeiro como agente capaz de operar a gestão do cuidado, com vistas a melhorar articulação deste último com o trabalho e educação e, desta maneira, a assistência à saúde da população. Descritores: Doença Crônica; Cardiopatias; Competência Profi ssional; Enfermagem; Promoção da Saúde. RESUMEN Objetivo: identifi car las competencias del enfermero relacionadas a la promoción de la salud de individuos con cardiopatías crónicas, a la luz del Consenso de Galway. Método: revisión integrativa de literatura basada en la búsqueda de artículos publicados en las bases de datos LILACS, BDENF, IBECS entre los años 2010 y 2014, y en el portal PubMed, en febrero de 2015. Se seleccionaron 21 artículos y se analizaron de acuerdo con los ocho dominios de competencias: Aceleración Nursing competencies in promoting the health of individuals with chronic diseases Competências do enfermeiro na promoção da saúde de indivíduos com cardiopatias crônicas Competencias del enfermero en la promoción de la salud de individuos con cardiopatías crónicas REVIEW


INTRODUCTION
Chronic diseases include all deviations from normality that have one or more of the following characteristics: permanence or presence of residual disability; not reversible pathological change in the body system; need for special training of the patient for rehabilitation; and long periods of supervision, observation and care (1) .
Among the chronic diseases, there are the chronic heart disease (CHD), clinical conditions characterized by progressive limitation of physical and functional capacity of the heart that cause impairments in activities of daily living, and would entail risk to life.They are responsible for high morbidity and mortality rates, and are considered a first magnitude public health problem (2) .
The CHDs bring significant impact on the patient's daily life and their families, representing a continuing threat to them, which highlights the need to use health care strategies, aiming at stabilization, clinical improvement, health and wellbeing, reducing the likelihood of hospital readmissions and premature death (3) .
Considering the complexity of the CHDs, assistance guided by the integrality and interdisciplinarity are fundamental for the promotion of health, recovery and restoration of the population health.Providing health means, besides preventing disease and prolonging life, ensuring means and situations that increase the quality of life, that is, increasing their capacity for autonomy and standard well-being (4) .In this perspective, so that care is directed to promoting the health of chronic cardiac patients to be effective, it is necessary for nurses to have specific competencies.
In the Galway Conference held in Ireland in June 2008, a consensus on global exchange and cooperation was agreed between countries in order to identify and build core competencies in health promotion and health education, as well as the development of the labor force (5) .This consensus pointed values and principles, a common definition and eight domains of core competencies required for effective engagement in health promotion practices.The domains are: 1) Catalyzing change; 2) Leadership; 3) Evaluation; 4) Planning; 5) Implementation; 6) Assessment; 7) Advocacy; and 8) Partnerships (5)(6)(7) .
Therefore, we can assume the importance of visibility of scientific production focused in nursing competencies within the health promotion of adult patients with chronic heart disease and justifying the interest in developing an integrative literature review of studies involving these competencies.
It is hoped that this study can contribute to a critical reflection of nursing care practices in promoting the health of patients with chronic diseases, aiming to improve the performance of nurses.Thus, a service that condenses this information will enable the nurse a better planning of their actions, and make them more participant in the care process.
In this perspective, this study aimed to identify the nursing competencies related to health promotion of adults with chronic diseases, in the light of the Galway consensus.

Ethical aspects
Since this is an integrative review, the study was not submitted to the Research Ethics Committee.However, we kept the ideas of the authors of the publications used in this study.

Design, study site and period
This is an integrative review, a research method that enables the synthesis of published studies, producing general conclusions about a particular area of research.It consists of a comprehensive analysis of the literature, which contributes to discussions about methods and research findings, while identifying knowledge gaps that can be filled with the performance of new studies (8) .
In order to conduct this review, six steps were followed: identification of the topic and selection of the hypothesis or research question; establishment of inclusion and exclusion criteria; definition of the information to be extracted from selected studies; evaluation of studies included in the integrative review; and interpretation of results (9) .Thus, initially, we formulated the following question: What are the nursing competencies related to health promotion of adult individuals with chronic disease?
The bibliographic search was carried out through consultations in databases, such as Latin American and Caribbean Health Sciences (LILACS), Nursing Database (BDENF), Bibliographical Index Spanish Health Sciences (IBECS) and National Library of Medicine (PubMed).This search was conducted in February 2015.

Sample and inclusion and exclusion criteria
On national databases, the following descriptors were used: heart disease; professional competence; nursing; and health promotion; according to MeSH terminology.On the international databases, the descriptors used were heart diseases, professional competence, nursing and health promotion, according to MeSH de Cambios, Liderazgo, Evaluación de las Necesidades, Planeamiento, Implantación, Evaluación del Impacto, Defensa de Derechos y Acciones Conjuntas.Resultados: se contemplaron todos los dominios de las competencias en las intervenciones del enfermero para la promoción de la salud de cardiópatas crónicos, sobresaliendo el Planeamiento y la Evaluación.Conclusión: los resultados de esta investigación posicionan al enfermero como agente capaz de organizar el cuidado con miras a la mejora continua de la articulación del trabajo y la educación y, como consecuencia, de la atención a la salud de la población.Descriptores: Enfermedad Crónica; Cardiopatías; Competencia Profesional; Enfermería; Promoción de la Salud.
terminology.The search strategy was ("heart diseases" AND "professional competence" AND "nursing" OR "heart diseases" AND "nursing" AND "health promotion").
The inclusion criteria defined for the pre-selection of the studies were: study written by nurses; consider the proposed objective; published between 2010-2014; restricted to English, Portuguese or Spanish languages; and fully-available electronically.We excluded: editorials, letters to the editor, studies published in event annals, reflection papers and repeated studies.
For description of the search and selection of studies we used the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA), as presented in the flowchart below (Figure 1).
The study selection process was carried out through close reading of titles and abstracts, so that studies that went to the final selection met the above mentioned inclusion criteria.At the end, we included six studies from LILACS database; Two from BDENF; one from IBECS and 12 from PubMed.Thus, the review was composed of 21 studies.

Study protocol
The review was composed of 21 studies, which are classified according to the level of scientific evidence proposed by Howick and colleagues (10) .

Analysis of results and statistics
For the final selection of studies, we conducted a critical and detailed analysis, making comparison with theoretical knowledge (9) .Initially, the data were collected through an observational script.
The results were presented in the form of boxes, charts and analyzed according to the eight areas of competence for the practice of health promotion, as defined in Galway Conference (5) .

RESULTS
In the characterization of the selected studies, it was observed that 12 (57.1%)were international studies.The United States and the Netherlands were the countries with the highest scientific literature on the subject, with two (9.5%) studies each; followed by China, Japan, the UK, Iran, Colombia, Sweden, Australia and Germany, with one study (4.8%) each.
With regard to national publications, it was observed that six (28.6%) were from the Southeast; two from the Northeast (9.5%); and one from the South (4.8%), the journals with the highest number of published studies related to the topic are the Revista Latino-Americana de Enfermagem with four studies (19%); and European Journal of Cardiovascular Nursing with three studies (14.3%).Regarding the years of publication, it was found that in the last five years, we highlight the years 2012 and 2013, with the largest number of studies per year, with seven (33.3%) and six (28.6%), respectively (Box 1).
After the classification of studies on the domains of competencies and nursing interventions (Figure 2), it was found that the most evident in the interventions of nurses in health promotion of heart disease were: Planning (81%) and Assessment (66.6%).
It was found that all domains of expertise were explored in the included studies, as shown in Box 2.
Studies excluded in the process: • LILACS: 03 (03 were about other topics).

DISCUSSION
It was found that most studies had a high level of evidence, being classified as high validity and relevance studies.In most of the analyzed studies, we highlight the intervention programs aimed at the planning viable strategies for promoting the health of patients with chronic diseases.
Building a competent workforce for health promotion with the knowledge and competencies required to develop, implement and evaluate policies and health promotion practices is key to integrate and sustain health promotion action (31)(32) .
The competencies have proven to be a foundation for training in health promotion, academic preparation and ongoing professional development because it corroborates the development of professional and quality assurance systems standards, and support the promotion of health as a specialized field of practice.Health promotion agents need specific education and training together with continuing professional development in order to maintain the particular combination of knowledge and competencies necessary to ensure the quality of practice of health promotion (33) .
The participation of health professionals as promoters of health is a proven effective strategy for improving the quality of life and prevention of complications arising from CHDs.In this context, the participation of nurses providing a scientific and competent care will meet the unique needs of the subjects received in health services and their families.
Important tools for the development of autonomy and empowerment of individuals and communities were found in some included studies (13)(14)(15)(19)(20)26,28,30) . The actions in his area are inserted in the domain "catalyze change", characterized by enabling transformation through individual and collective training to improve health (31) .Health education and empowerment are clearly effective tools for disease prevention (30) .This fact could be observed in a study conducted in a center of cardiac rehabilitation whose results showed that patients monitored regularly by nurses, receiving information about the disease and control measures, had fewer complications of the disease, when compared to the control group (15) .
From the Ottawa Charter on Health Promotion, it is strongly argued that the empowerment of individuals and communities are important tools to gain ownership and control over their health.The concept of empowerment has been the main health promotion focus (19)(20) .
The educational actions in health can empower individuals and groups in the construction of new knowledge, leading to consistent preventive behaviors or health promotion practices (20) .Individual and group educational meetings, home visits (HV), tele-nursing and printed booklet are valid methodologies for promoting self-care behaviors (17) .
It appears that the activities developed for health promotion require the intervention of the social and economic spheres, beyond the health sector, as it includes the participation of all
To meet these principles, the nurse should value the leadership competence that allows the professional to produce a strategic direction and opportunities for the development of healthy public policies, mobilization and management of resources for health promotion (31) .
In a study evaluating the impact of a program for the prevention of Cardiovascular Disease risk (CVD) in patients discharged after an episode of acute coronary syndrome, there were changes in relation to risk factors.The program was coordinated by nurses and developed in secondary and tertiary care units, and covered guidelines which had focused on healthy lifestyle, biometric risk factors and medication adherence, in addition to usual care.The authors found that, in a year, the program resulted in reduced risk for CVD (17.4%) and the reduction of re-hospitalizations (34.8%) (13) .
Therefore, the importance of enhancing the implementation of integrated and inter-sectoral interventional actions of health promotion and prevention, individually and collectively, help people to modify risk behaviors and to adhere to healthier living habits (35) .
From this perspective, interdisciplinarity and intersectorality appear as coping strategies of multiple health problems that have affected people with CHD, especially for professionals contributing in the process of discussing and reflecting, which are fundamental requirements in the process of care.Health promotion requires technical competencies in engaging and facilitating the participation of various sectors in partnership working and implementing intersectoral strategies (5) .
Thus, diagnosing the psychosocial context, support networks, identification of cardiovascular risk factors and barriers to treatment and assessment of lifestyle are essential actions in chronic cardiac disease patient care and are inserted into the competence of diagnosis (24) .In this perspective, the nurse is one of the professionals involved in the diagnosis of the community, that is, conducting community assessment, identifying and analyzing behavior, culture, social, environmental and organizational aspects, which can be instrumental in promoting health or impairing it (31) .
Nevertheless, despite the efforts made in the control of CHDs, the evolution of these patients have not changed significantly, at least in regard to hospital mortality and readmissions, because in general, the CHDs are caused by several factors, together they will trigger the disease.Most of them are related to the lifestyle of the population, diet, physical inactivity, excessive weight, high waist circumference, alcohol consumption, smoking, stress level, quality of the environment they live in.Thus, they can be avoided, since the main causes are not related to genetic factors, but modifiable factors related to the environment and behavior, as shown in a study on risk factors for cardiovascular disease among nursing professionals (35) .
Consequently, in order to cause change in the safety culture of the health care facilities of patients with CHD, professionals must have knowledge and competencies to identify modifiable factors and know what to do, since the promotion of health has its base in lifestyles, the new orientation focused on social and environmental factors.This fact confirms the complexity of the therapeutic regimen and it requires a significant challenge for health professionals, since there are many gaps and inefficiencies in the management of these patients (11)(12) .
The stimulus for the participation of the person who has chronic heart disease in their treatment is also part of clinical care in cardiovascular nursing.The nurse's role in this context should prioritize the strengthening of an empathic relationship, acceptance and recognition of the limitations (20) .
The diagnostic competence guide the nurse professional to the domains of planning and implementation.While the planning domain is described as the ability to establish measurable goals and objectives in response to the needs assessment, implementation is the way to effectively perform these strategies (31) .
In this context, the follow-up of patients in their residence allows the nurse to implement their actions in a real environment in which the individual is inserted.Authors sought to determine the effect of a nursing educational intervention resulting from the combination of HD and telephone contact for a period of six months to patients with decompensated heart failure (DHF).The results showed improvements in blood pressure control, proper weight maintenance and adherence to the use of prescription drugs and fewer readmissions (16) .
In addition, the nurse should be able to stimulate communication between the staff, the patients and their families in order to promote health and to involve everyone in care.The nurse demonstrates competence in the domain "partnership" when they create an environment of mutual trust and establishes partnerships with patients; conveying a sense of being present with the patient and providing comfort and emotional support, reflecting upon this process and using this knowledge to additional therapeutic interaction (13,16,19) .This dialogic relationship -in which professionals, patients and families should understand that success depends on shared decision -the important role that nurses play in the individual's empowerment to promote care and health.Therefore, we conclude that the domains "catalyze change", "leadership" and "partnership" are interconnected.
Planning is well explored in studies that make use of a systematic process of care.In the topic, we highlight the Nursing Process (NP), means that enables the implementation of a broad theoretical framework of nursing clinical practice, making individualized care possible, in an ordered manner and directed to results (14,22) .
In the context of patient care with heart disease, the NP should be understood as a complex technological model that allows us to offer comfort, physical and mental well-being of the patient.In a study that sought to use NP in 30 patients hospitalized for cardiovascular disease, it was shown that the list of nursing diagnoses was associated with a better analysis of the responses to cardiovascular disease (25) .These findings corroborate with other researchers (3,14,22) .
Another way of planning is through the development of action and coping plans, as evidenced in the study (21) held in Brazil, with 59 coronary artery disease patients.The plan of action and barriers to face for making the associated behavior to time counters and the sleep/wake cycle.The authors found that non-adherence was related to forgetfulness and lack of routine.Thus, the action plans focused on these parameters allowed them to change behavior to the prescribed therapy.
In implementation, the strategies should ensure the greatest possible number of improvements in health, including the management of human and material resources (12,27,31) .In the studies analyzed, it was found that follow-up strategies for telehealth, development of empowerment actions, access to health services strategies, cardiac rehabilitation programs, coping with obstacles, behavioral interventions and health data analysis examples that should be considered for promoting the health of cardiac patients.
Among the various approaches to the care of people with chronic heart disease, it appears that the combination of an inhospital educational program followed by telephone contact made by nurses after hospital discharge has provided health improvement in quality of life of patients and their families.
An European study (18) implemented a telephone monitoring program for patients with Acute Myocardial Infarction (AMI) and patients with angina pectoris, the Hartcoach.The program consists of monitoring patients for a period of six months, in which the guiding nurse advised regarding the importance of patients taking their responsibility in managing their health, and sought to identify modifiable risk factors (17) .Through this technology, the authors were able to identify cardiovascular risk factors (weight, waist circumference, blood pressure, physical activity and diet) and adherence to pharmacological treatment, self-care and quality of life.
Experimental research conducted in Brazil, with similar objective, found that in-hospital educational intervention, in addition to telephone contact, enabled a better understanding of the disease and self-care (26) .
Determining the scope, effectiveness and impact of policies and health promotion programs include the appropriate organization of evaluation and research methods to support the improvement of programs, sustainability and dissemination (31) .It appears, therefore, that the importance of evaluating the results of the intervention is a key measure for the re-planning, if necessary, or continue actions.
The patient and communities' advocacy, another domain of competencies found among the studies analyzed, aimed at improving the health and well-being, to promote important aspects of quality of life and health promotion (31) .In patients with chronic heart disease, the advocacy role involves defending their interests, enabling the improvement of health and adherence to therapy.
Interventions to improve adherence to drug and non-drug therapies have been developed and evaluated, however, those based on theoretical assumptions deserve special mention, especially the theories that focus on the intention or motivation to perform certain behaviors (26) .
A study demonstrated the effectiveness of interventions with different theoretical framework to encourage the adoption of healthy behaviors, with the performance of physical activity.The authors reported positive results with the use of action and coping strategies in order to optimize adherence to physical activity in patients enrolled in a cardiac rehabilitation program (21) .
It is noteworthy that in the Unified Health System (SUS), the nurse should be able to promote community empowerment.To this end, advocacy is an extremely valuable competence, nurses should advocate on behalf of individuals and communities, acting in defense of healthy public policies and creating supportive environments (31) .
As stated, important skills were identified and discussed as the Consensus of Galway.However, it is noted that methodological circumstances limited broader results.The difficulty of access to full text studies from some databases are configured as a limitation, since other competencies may not have been contemplated.

FINAL CONSIDERATIONS
A total of 21 studies on health promotion nursing competencies for patients with chronic heart disease were analyzed.According to the data presented in this study, there are several competencies that nurses develop, such as: comprehensive approach to assessment of the psychosocial context; health education; development of empowerment strategies; preventing diseases; assessment of lifestyle and promotion of partnerships between patients, families and professionals; planning; and evaluation.
The most evident domains of competencies in the publications were: Planning, Implementation and Evaluation.It is noteworthy, however, that all domains have been reported.Undoubtedly, competencies are conceptualized and allow the nurse to highlight as an agent capable of operating resource management, with a view to improve articulation with work and education and, thus, the health care of the population.
As limitation of this review, we highlight the fact that much of the scientific knowledge produced on NCDs come from developed countries.To guide the development of effective interventions, broadening the understanding also in the context of low and middle income countries, for which new studies are very important, is imperative.
It is noted that the results of this study will support the conduct of nurses in the practice of health promotion in patients with chronic heart disease and encourage nurses for the adoption of the strategies discussed here.

Figure 2 -
Figure 2 -Studies of each domain of competencies of nurses inpromoting the health of patients with chronic heart disease, 2015