Taking a look to promoting health and complications' prevention: differences by context

ABSTRACT Objectives: to acknowledge and compare the health promotion and complications' prevention practices performed by nurses working in hospital and primary health care contexts. Methods: descriptive, exploratory and crosscutting study, performed with 474 nurses selected by convenience sampling. It was used a form that encompassed two categories of descriptive statements about quality in the professional exercise of nurses. This study had ethical committee approval. Results: the nurses' population was mainly women (87,3%) with an average age of 35,5 years. There was more practices of the hospital's nurses related to the identification of potential problems of the patient (p=0.001) and supervision of the activities that put in place the nursing interventions and the activities that they delegate (p=0.003). Conclusion: the nurses perform health promotion and complications' prevention activities, however not in a systematic fashion and professional practices differ by context. This study is relevant as it may promote the critical consciousness of the nurses about the need of stressing quality practices.


Introduction
Health promotion and complications' prevention are two descriptive statements of the quality standards for the professional exercise of nurses in Portugal. Nursing care quality standards were established in 2001 by the Portugal Order of Nurses, aiming to improve the services performed by these practitioners, and gaining visibility to the professional group with regard to the role that hey have in society as a whole (1) , at the same time being part of their performance evaluation.
The World Health Organization (WHO) defined health promotion in 1986 as "the process that trains individuals to get grasp of and improve their own health (2) ". In this sense it is understood that individuals need to develop capabilities and competencies to enable them to adapt to the different stages of the vital cycle and to their health/illness processes in an effective way.
Nurses may help to foster this process. For that end they need to place the patient in the center stage of care and be able to perform a holistic analysis of the person, family groups and community in a way that allows identifying their peculiarities in the realm of health promotion. The patient-centered care demands for the comprehensiveness of the health promotion activities within the nurses' clinical practice, thus being a requisite for their professional practice.
Implementing interventions in the realm of health promotion, directed towards empowering of the patient and developing coping strategies, may help to manage the weaknesses that a chronic disease carries in itself.
These interventions are even more remarkable in the situation when there are low availability of psychosocial resources, such as those of social isolation and loneliness, low self-esteem, feeling unsafe, exhaustion, depression and low socioeconomic level (3) , conditions that are frequently associated to chronic disease conditions.  (5) . Thus, health promotion becomes actually the aim of the attention of the whole society.
In spite of this, the health promotion concept is oftentimes mistaken with the complications' prevention, being the latter related to the potential problems of the patient and to the risks that are intrinsic or extrinsic to the individual, problems that frequently demand the nurses' interventions for their control.
In this perspective and considering that the     The groups show differences regarding the sociodemographic variables, and those differences are statistically significant. The answers of the interviewees are statistically significant for all questions.
The practices of nurses regarding the quality standard health promotion, analyzed by health institution are presented in Table 3

Discussion
The largest share of nurses that were part of this study are women in the sample as a whole and also in the population of each institution. This is also pointed out as a national and international fact, as the prevalence of females in the Nursing profession is still true nowadays and for a long time (7) .
The nurses' practices regarding the quality standard complications' prevention, analyzed by health organizations are shown in Table 4. provide information that will foster the cognitive learning and new capabilities for the patient. Not withstanding this fact, they do not perform these practices in a systematic fashion, once that is observed that the prevalence of the category "sometimes" is larger than the category "always".
In this quality standard, there was also a significant difference between the practices of nurses in the two contexts, in relation to the promotion of healthy lifestyles that is a more permanent practice in practitioners acting in primary care in this study. This is also seen in other contexts. A study in Australia reveals that even having evidence that nurses are efficient making interventions for health promotion, it is still needed to enlarge their competencies and expand their interventions to other contexts beyond primary care, as they have a considerable potential in this field (8) .
In the same fashion, in the category of the quality standard for complications' prevention, the most cited answer is "sometimes", excepted the statement "Nurses show responsibility for their decisions, for their acts and for those that they delegate". Nurses in a non-systematic way: identify the potential problems of the patients; prescribe and implement interventions geared towards the complications' prevention, assess the interventions that will help to avoid problems or minimize undesirable These results show that nurses in primary care are more comfortable using the development and community extension models in their practices, based in the social framework of health, than the hospital's nurses. This confirms the findings of other studies that reveal that health promotion activities are more strongly performed by primary health care nurses (11) .
The physical aspects of illness have guided the clinical practices in the hospital context and in this milieu, nurses not only are not associating health promotion to their practices, but they also consider it a second level priority (12) , hampering the development of health promotion in hospital environments (13) , even though it is considered a crosscutting, multi and interdisciplinary strategy.
The request to use the principles of health promotion in all organizations, including hospitals (14) , pre-supposes to consider this environment not only as a curative or illness-preventative context, but also as a factor promoting healthy life (15) , oriented towards training the patients to be active agents in the process of managing their health and illness. With better the Rev. Latino-Am. Enfermagem 2016;24:e2749 adherence of the patients to their health processes, the safety will be improved, better health results will be achieved, costs will fall (16) , effectiveness of interventions will be achieved, as well as quality of life and health expectancy that go beyond the economic benefits for the client, the family, the society as a whole, and the health system.
Supply of preventative health services may rise health levels and prevent illnesses (17) . Systemizing nursing practices may help to make effective the requisites needed to implement the interventions that go hand in hand with the implementation to the complications' prevention.
On the other hand, the programs for health promotion may foster self-protective behaviors, responsibility for own health, community participation and adoption of healthy lifestyles (18) . Nurses have a privileged role in the implementation of health promoting interventions (19) independently from the context where they practice. However, they have sparse proactivity in regard to the adoption of health promotion and self care measures. The care is delivered in a fragmented manner (20) leaving doubts about its effectiveness, low motivation and lack of training (21) .
Considering that health promotion is associated with the universal principles of Nursing, nurses should have knowledge, competency and skills to articulate its actions in their clinical practice, being this practice in the hospital or primary care contexts. (22) .
Under this perspective, it is needed to re-structure professional practices, implying previously a change in the mindset that substitutes the bio-medical paradigm approach by the paradigm that generates health, a process that needs individual adaptation and professional competency development to foster knowledge, skills, attitudes and consciousness in the patients as prerequisites for efficient self-care.

Conclusion
The results of this study allowed the understanding of how the Portuguese nurses articulate in their clinical practices the interventions regarding to quality standards, health promotion and complications' prevention. Not withstanding this finding, this process is not performed in a systematic manner and professional practices diverge according with the context.
Nurses need to involve themselves deeper with the practices that put in operation the quality standards, not just because they need to conform to professional norms linked to their performance quality, but also because they may fulfill higher purposes associated to raising the visibility of the role of nurses in society.
We need to remark, as a study limitation, the fact that we examined just two different institutional contexts and two categories of standards for quality of nursing. For a wider vision of the Portuguese practitioners ownership of the quality standards of nursing care as stated by the Portugal Order of Nurses, it is suggested to develop larger studies, at a national level and approaching all the categories of the quality standards that are inherent to nurses' professional practice.