Skills for generalist and specialist nurses working in the prevention and control of infections in Brazil*

Objective to define the competencies for the prevention and control of healthcare-related infections that should be developed by the generalist nurse and the specialist nurse in infection control in Brazil. Method the Delphi technique, developed in four rounds, was used. Thirty-one nurses and eight physicians participated in the study, with expertise in infection prevention and control. Data were collected using open-ended questionnaires, whose answers were treated using the content analysis technique. Structured instruments were used to evaluate the importance of each competency using a Likert scale. Data were analyzed and presented in a descriptive way, use of median and coefficient of variation. Results the competences were organized in 4 core, 14 generic and 17 specific, with name and description of each competency. Conclusion the definition of competencies for the prevention and control of healthcare-related infections is the first step to begin the rethinking of the teaching and learning process in the initial training of nurses. The data found in the present study may help to restructure education and support permanent education programs in health.


Introduction
The teaching of prevention and control of healthcarerelated infections (HCRI) has been pointed out by national (1)(2)(3)(4) and international studies (5)(6)(7)(8)(9) as an area of great weaknesses related to the knowledge of health professionals on this topic, which reflects in the care practice, where there is great unpreparedness of the health team to employ the necessary measures for the prevention and control of HCRI. Also, the teaching of this area needs to be rethought and restructured aiming to establish professional competences must be learned from the beginning of the nurse's professional training.
In this way, it becomes necessary to know the competences that nurses must acquire so that their professional performance is based on the principles of prevention and control of HCRI. Enabling these competencies to be developed in the training process during the undergraduate course represents a great challenge.
Conceptually, competence is the articulation of three dimensions: knowledge, skills and attitudes necessary to reach a given objective (10) . In the year 2015, a systematized research was carried out in the literature to identify studies that would serve as foundations for the generalist nurse training process. However, all the works found were international, from the United States, Canada, the United Kingdom, Australia and Taiwan (11)(12)(13)(14) , which describe competencies for generalist nurses and specialists in prevention and control of HCRI.
Many aspects of HCRI prevention and control, such as evidence-based prevention indicators, apply in any country. However, considering the particularities that permeate the professional practice, influenced by the organization of the health systems of each country and in view of the identification of this gap in the Brazilian nursing production, the present study aimed to determine the competences for the prevention and control of HCRI that must be developed by the nurse in Brazil, constituting a guiding axis to rethink the teaching of this theme.
In addition, the objective is to differentiate the skills of the generalist and specialist nurse in this area, contributing to the advancement of debates, teaching and practices of nurses, becoming a support for other countries to use this classification to validate and develop skills of nurses in their territories.
This research aims to define the competencies for the prevention and control of healthcare-related infections that should be developed by the generalist nurse and by the specialist nurse in infection control in Brazil.

Method
The present study was developed using the Delphi technique, an efficient method to generate consensus on a complex problem, based on the opinion of experts in the subject (15)(16) . These data were organized and analyzed according to the principles of content analysis (17) , considering the classification of core, generic and specific competences.
Core competencies correspond to those common to all health professions. The generic ones are those common to a professional field of knowledge and, in this study, are considered the competences for the infection control that the generalist nurse must have developed upon graduation.
Specific competencies correspond to those inherent in a profession or specialty. In this study, it encompasses the competencies expected for a specialist nurse to perform the infection control and that they need to acquire at the end of the specialization course in the area of prevention and control of HCRI.
After the analysis of this round, a list of competences was elaborated, which consisted of 10 core competencies,

Results
The results are presented from a list with the competences (name and description) that obtained a consensus among the participants, considering their classification, ending with 4 core, 14 generic and 17 specific competences, according to Tables 1, 2  Deepening of the process of analysis and discussion of the data to structure the curricular proposal Analysis of the data from the 2nd round supported the construction of the third instrument, seeking to clarify widely-varying issues Analysis of the data from the 3nd round supported the construction of the fourth instrument with the partial handing back of data.
Source: (16) .  Ethics means to understand the concept of ethics and work in an ethical way in all the situations in which one is involved.
The generic competences for the control of infections for the generalist nurse make up Table 2. Recognition of the problem of healthcare-related infections 17% Collaboration with epidemiological surveillance and knowledge of the epidemiological profile of health services 17% Management of exposure to biological material 17%

Implementing infection prevention actions 17%
Cleaning, disinfection and sterilization of health products/equipment 13% Cleaning and disinfection of environments and surfaces 12% Care for the infected patient 12% Use of standard and specific precautions 11% Recognition of the process of the microbial transmission chain 11%

Identification of risk for infection 11%
Use of Personal Protective Equipment 9% Hand hygiene 7% *It was considered as consensus the competences that reached median 5 and coefficient of variation less than 20% Maintenance of the aseptic chain is understood as the competence to recognize the process of the chain of transmission, to know the principles of asepsis and antisepsis, to master the techniques necessary for the maintenance of asepsis of a procedure, recognize and intervening when there is a breakdown of asepsis during a procedure.    (18)(19)(20) and international (21) studies that emphasize the importance of these competencies for health professionals. These are structural elements in the process of production of health care, favoring the safety of patients and professionals in health services, as well as their quality and efficiency.
The generalist nurse is considered to be a professional capable of developing care at any point in the health care network and, therefore, their training must encompass knowledge, skills and attitudes that enable the student to develop competences for the comprehensive care of the clients of the different health services (22) . studies that approached this subject (11,(13)(14) . This fact evidences that the problem of HCRI is worldwide and, although there are epidemiological differences between regions, prevention and control measures are applicable in any context and, therefore, are necessary for the training of nurses in a similar way.
A pioneer study (14) in the definition of competencies for the prevention and control of infections for health professionals, conducted Canada in the year of 2006, has been used as a parameter by the subsequent studies.
An American study (13) also adds competence to the management of disasters involving infectious diseases.
Thus, it becomes evident the importance of a national study that contemplates the vision of Brazilian professionals with expertise in HCRI prevention and control, favoring the delineation of competences according to the needs of the national health services.
Regarding the specific competences that the specialist nurse in infection control needs to have built at the end of his/her specialization, a great consonance of these findings was identified with the competencies that are presented in international studies (12,(23)(24) .
It is important to point out the importance of the specialist nurse, who is responsible for program management and for articulating government recommendations and research that produces guidelines and evidence to support HCRI prevention and control actions.
The definition of competencies for the prevention and control of HCRI for generalist and specialist nurses is not intended to evidence or promote hyperspecialization, but rather to emphasize the importance of general practitioners so that the consolidation of these practices contributes effectively to the quality and safety of health care.
As HCRI prevention and control are a recurring theme in all health care areas and have a differentiated connotation at the time of its approach and development during undergraduation, they must be developed so that the student is prepared for the application of these generic skills for the prevention and control of HCRI in all health services.
The differentiation of generic and specific competences does not intend to fragment or isolate them, but to distinguish them, differentiating them and at the same Future studies can contribute to the improvement of the description of these competences, detailing them from the dimensions of a competence: knowledge, skills and attitudes (10) , thus contributing to the expansion of the pathways for its implementation in nursing undergraduate courses and specialization courses.
The absence of participants from the Northern region of Brazil constitutes a limitation of this study.
However, considering the peculiar universality of the identified competencies and, still, the similarity found with international studies, we believe that the results can be extended to that region. Still, we believe that it can contribute to researchers and professionals from other countries that seek to develop the subject in their territory, being the basis for the organization of these competences.

Conclusion
From Brazilian professionals with expertise in the area of prevention and control of HCRI, it was possible to develop and register generic and specific competences for the national scenario.
The definition of competencies for the prevention and control of HCRI is the first step to begin the rethinking of the teaching and learning process in the initial training of nurses, establishing the moments in which each competency is developed throughout the course. Similarly, among nursing professionals, these competencies can be used to define permanent health education programs.
In addition, these results can contribute in the international scope, since there is a global need of restructuring of the teaching of these competences during the training of the new nurses.