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Revista Gaúcha de Enfermagem

On-line version ISSN 1983-1447

Rev. Gaúcha Enferm. vol.39  Porto Alegre  2018  Epub Aug 02, 2018

http://dx.doi.org/10.1590/1983-1447.2018.2017-0152 

ORIGINAL ARTICLE

Competencies of the nurse in educational institutions: a look from educational managers

Flor Marlene Luna Victoria Moria 

Sebastián Bustamante Edquénb 

Zoila Esperanza Leitón Espinozaa 

Rosario Santillán Salazara 

a Universidad Nacional de Trujillo (UNT), Facultad de Enfermería, Departamento de Enfermería del Adulto y Anciano. Trujillo, Peru

b Universidad Nacional de Trujillo (UNT), Facultad de Enfermería, Departamento de Salud Familiar y Comunitaria. Trujillo, Peru

Abstract

OBJECTIVE

Describe and analyze the attributes of the nurse competencies in caring of students since the manager look of educational institutions.

METHOD

Qualitative descriptive-exploratory study. Seven principals of educational institutions of Trujillo (Peru) participates in a non-structured interview during the first semester of 2016 and the analysis of oral discourse was used.

RESULTS

Empirical categories: The nurse in the promotion of educational community health; The nurse in the prevention of the educational community illness; The student nurse articulating health - education in the everyday life of students.

FINAL CONSIDERATIONS

This study contributes to the conceptual support of the competencies of the student nurse for the intersectoral health - education action and the setting-up of health with students in the educational institutions.

Keywords: School health; School nursing; Needs and demands of health services

INTRODUCTION

Adolescents represent 20% of the total population of the world, and 85% of them are in developing countries. Regarding South American countries, Peru is the fourth with the most teenagers, after Brazil, Colombia and Argentina. Considering the entire Latin America (20 countries), Peru is the fifth, after Brazil, Mexico, Colombia and Argentina. From 1960 to 1990, it is estimated that the number of adolescents from 10 to 19 years of age in Latin American increased 138%. Similarly, the population from 10 to 24 years of age reached 155 million people, representing one third of the total population of Latin America and the Caribbeans1.

Human development allows for people to freely reach their highest productive and creative life potentials, while treating with respect everything around them2. This type of development can be achieved by protecting the student-aged and young adult population, who are still developing their competencies. The best places to do that are educational institutions3. For adolescents to fully develop, they need access to health, well-being, education, justice, employment and social participation, in addition to supportive family and community that help guiding their evolution. Consequently, we are led to find connections between the health sector and the educational sector, promoting health and development of adolescents and young adults.

It is, however, important to consider that 13.9% of adolescents from 15 to 19 years of age have already been pregnant at some point. The highest percentage of teenage maternity involve women who only had basic education (36.2%), live in an isolated rain forest area of Peru called Selva (23.7%), are in the lowest financial tiers of society (23.9%) and those who are rural areas (20.3%). The lowest rates are in the metropolitan areas of Lima (10.6%), and among women with higher education and in the highest financial tiers of society (8.5% and 5.6%, respectively)4.

With regards to nutritional health between 2000 and 20134, anemia among female adolescents from 15 to 19 years of age fell from 29% to 17.7%. However, there is an increasing preoccupation with the growing cases of overweight, which now affects 23.6% of male and female Peruvian adolescents, and is more frequent in urban zones than in rural ones.

Taking into account the educational aspect, the number of adolescents in high school has increased. The coverage of this level of education reached 81.5% in 2014, while the percentage of adolescents which finished high school in the appropriate time - when 17 or 18 years old - grew from 49% in 2013 to 64.8% in 2014. A comparison between urban and rural environments shows very different settings. While 73.2% of adolescents from urban areas do finish their high school in regular age, only 42.3% of those from rural areas do the same.

A study5 which verified the physical conditions of adolescent when compared with reference values for Peru and international ones, revealed low levels in all evaluated physical variables. It found that 100% of all ages evaluated were overweight, and it is widely known that consumption habits that lead to obesity are consolidated in the school years of a child. Cross-sectionality in education should include health education itself as a part of the formation of adolescents in school. This further supports and justifies the presence of nursing professionals in the schools, who should be responsible for guiding and promoting a healthy lifestyle among school aged children, which includes, among other things, physical activities6.

Schools offer an interesting environment to promote health, as they make it possible to reach thousands of millions of children all around the world, also reaching, through them, school workers, families, and the community as a whole7. Messages of health promotion can be reinforced through the most relevant stages of the life of children, thus giving them the competencies needed to develop permanent attitudes and aptitudes. The ideal professional for these actions is the nurse, inside the public schools, from a perspective of complex focus, that is, one that is holistic. Under these principles, a healthy school can be conceived within an organization of interdisciplinary and intersectoral work, allowing for the acquisition of knowledge, which would make it easier for a human being to develop: whether they are school students, children, adolescents, or young adults, for all of them, that means knowing and exercising their citizenship8.

If we apply complex thinking9 to this reality, we would say that the interpretation and understanding of many natural phenomena generally require a distinct type of thought, and that is where planning for the development of complex thought in human beings stand out as a way to guide individuals and nations towards well-being, evolution and reproduction. The future of a science that is conscious while seeking to offer new discoveries is in the development of complex thought in students and teachers.

Offering primary care nursing services for health promotion, well-being and prevention of health problems of students, as well as providing all educational institutions of the country with nursing professionals, to guarantee an effective and integral health protection and the development of guarantees and rights which are established in the 7th article of our Political Constitution, and incorporating the concept of health promotion in schools, signals that these institutions promote health, trying to advance in the integration of health and education sectors wherever they are. This is where educational managers have an important role, since it is up to them to see or not the need of nursing professionals in educational institutions, as well as to sensitize the universities to the competencies that they have to form in the nurses for primary health care within the Educational Institutions. This raises the following question: What capabilities must the nurse in educational institutions have, according to educational managers? That leads to our objective: describing and analyzing the attributes of the capabilities of the nurse in the health care of students, as perceived by the managers of teaching institutions.

METHOD

This is a descriptive and exploratory study, with a qualitative approach. The study took place in the city of Trujillo, which is in the northern coast of Peru, nearly 500 km from Lima. The material of the study included the Educational Institutions (EIs) of the Trujillo district, represented by their directors: managers. The number of participants was defined through data saturation, according to the precepts of qualitative investigations. All data presented in the study was found through individual and non-structured interviews with seven educational managers, following a guide which included the following open questions: What do/would nurses do in the EI you manage?, What other competencies/functions must a nurse have in an EI?, What else can you say about the nurses in the EIs? Data collected in the interviews was recorded using a voice recorder, and then transcribed and stored in a word processor. Data was collected during the first semester of 2016. Selection criteria included: Educational institutions with a school population above 500 students. Managers with at least one year in the position, who accepted and were available to participate in the investigation.

The recorded material was transcribed immediately after data collection. Data obtained from the interview with the participants was examined. An analysis of the oral discourse was conducted according to Orlandi10, and then the information was collected for the elaboration of the categories of the competencies of nurses in the Educational Institutions (EIs). In order to elaborate them, a register of key codes was created. The codes reflected the central concepts present in the discourse of the participants, to characterize the competencies that, according to the managers, nurses must have in the EIs. The managers were guaranteed that the participation was free, informed and anonymous. The identification of the oral narratives uses the capital letter P, for Participant, followed by number which indicates in which order participants were interviewed (P1, P2, P3, P4, P5, P6, P7).

ANALYSIS AND DISCUSSION

In this study, after analyzing the material from the interviews and contrasting it with the theoretical framework, data was categorized through the description of competencies and attributes of nurses which the managers of educational institutions reported as necessary for "school health".

Health is not only the absence of diseases, involving everything that surrounds children and adolescents: their eating habits, games, ambitions, desires, and education; it is known that in a few years they will be the economically active population of Peru, and that is why their formation and development is under careful consideration: in the future, they will be the column of our country.

After interpreting and analyzing the oral discourses, three empirical categories emerged: 1) competencies of the school nurse in the health promotion in the educational comunity, 2) competencies of the school nurse in the prevention of diseases in the educational community, and 3) competencies of the school nurse in the articulation of health-education in the daily life of school children and adolescents.

Competencies of the school nurse in the health promotion in the educational community

The inclusion of nurses in educational institutions will lead to a strengthening of primary care attention, due to the health promotion in the EIs. It is simultaneously the process that allow for people to increment their control over their own health to improve it, involving not only actions targeted at increasing competencies and capabilities of people, but also those targeted at modifying environmental and social conditions. The directors of the educational institutions that participated in the interview state similarly that:

Having a nurse in the school makes teachers and parents feel safe, here we have a local nurse, who coordinates with the psychologist so that they can give informal speeches to strengthen the self-esteem and emotional maturity. That leads the students to have better academic results. (P1)

The option of having a nurse working is very good because "two heads think better than one" and the students need to improve, strengthen their health, we have students that sleep in class, others who miss or don't understand them, maybe they don't have good breakfasts, or have a breakfast that makes them sleepy. Now we are working with healthy lunch-break snacks, healthy breakfasts, and the nurse would help to improve the customs and habits of the students, teachers and parents. (P6)

This makes it clear that from the perspective of educational managers, the presence of the nurse makes them feel "safe", and we know that the presence of the nurse is care in itself. As ratified by this statements, the nurse takes care of self-esteem, emotional maturity, eating habits11 - which is to say that the presence of nurses would strengthen the Educational Institutions (EIs) that do not have nursing offices as well as health promotion, healthy lifestyles, self-esteem, self-image, emotional maturity, mental health, in addition of improving eating habits with healthy snacks, breakfasts, cleansing of hands, teeth, drinking of sterilized water, as well as helping the school community to change, improve their habits - not only those of the students, but those of the entire community, including teachers and parents. The managers of educational institutions and the parents themselves recognize that.

The broadening or migration of the nurse to the educational sector as a space for professional practice leads one to say that the success and quality of nursing care, in the case of this study, for students, "... is based on the knowledge, skills, and capabilities of the nurses"12, understood as the competencies of the school nurse, which broadened the space in which they act from the health sector to the schools. This demands knowledge about the health situation of the students, and of the competencies that are demanded for one to work in primary health care, that is, in the first level of attention.

The Ministry of Education develops the Program for the Promotion of Health Lifestyles, which is articulated with the Program of School Eating Habits. The promotion of healthy lifestyles is understood as the development of competencies and attitudes of boys and girls, so that they can take pertinent decisions for their health, growth, and life ambitions, considering their individual well-being as part of the collective one. The program has the purpose of offering, to territorial entities, conceptual, pedagogical and operational guidance to guide the educational establishments in the construction of cross-sectional pedagogical projects that can contribute to the development of knowledge, competencies and attitudes in boys and girls so that they can take pertinent decisions about their health, growth and life projects, considering their individual well-being as part of the collective one. However, the nurse is brought from outside of the gates of school into the educational institutions, and that would change if the nurse was a permanent worker in the school. Since the early days of the profession, nurses have proclaimed that a person is a whole that needs to be approached from a holistic perspective. However, nurses have hegemonically been formed to have clinical and hospital profiles, barely including life promotion and health prevention, which, according to the aforementioned statements of the educational directors, promote life, a life that takes place at home and at school13).

As nurses, members of the health team, it is important to work for a change in this health paradigm. That means emphasizing health promotion and prevention, and not recovery: "healing in a hospital". A change of paradigm implies in understanding that using money to improve one's health is not a waste, but an investment. If students have healthy practices: such as physical activities, clean hands, and others; if they have an environment free from tobacco smoke, if they consume fruits and vegetables, we can diminish and avoid the contraction of many transmissible diseases in their future states of life.

The role of the nurse in schools is also important to detect and take action in situations where there is suspicions of bullying, sexual abuse or child abuse, in order to promote healthy lifestyles and sexuality. In the words of the managers, it [...] strengthens self-esteem and emotional maturity, and, therefore, improves learning and academic results. Without trying to imply that this is a "mathematical logic", if children and teenagers are healthy, their pupils will be healthy.

The nursing profession, from its emergence to recent days, has evolved and occupied non-traditional spaces, due partly to the requirements of society and partly to technological advances (hard and soft technologies) which make it so that our profession is constantly being (re)created. In this study we discuss and analyze the space of the nurse in the schools.

Competencies of the school nurse in the prevention of diseases in the educational community

Health promotion and disease prevention are two inseparable and complementary concepts, since promotion refers to the stimulus of protective factors for the life of the population, fomenting healthy and safe lifestyles, nurturing body, mind and spirit, while prevention is related to the control of conditions and determining factors that can prevent diseases or their worsening. The directors manifest an opinion as thus during the interviews.

The students start to smoke, although it is forbidden and they know it, they come to school with their clothes smelling strongly of cigarettes, for some of them alcohol consumption started at 10, 12 years of age, it is worrying, because in some cases we don't have the support of their parents. (P3)

It is known that the prevention is the essential and most desirable objective for dealing with a disease, but in the case of addiction, the situation becomes more complex, due to the number and variety of substances, their effects in individuals, and the social and legal context in which they find themselves.

The nursing professional not only takes action but also shows an "attitude of care"14, exercising leadership and making their actions, the correct actions, visible, in a space where they can affect children and adolescents, whether healthy, or with chronic or acute health problems. The nurse has the ability to plan, execute and evaluate health and social problems, conduct investigations and education according to each reality.

A bill15 currently being analyzed by Peruvian Congress, presented for evaluation and discussion by the Panel of Nurses of Peru (CEP), incorporates nursing professionals to all educational institutions in the whole country of Peru. In its third section, about its objectives, it indicates that "the norms and procedures contemplated in this bill will guide the competencies of the school nurse in the different educational entities that offer services of school health", in order to achieve objectives such as: early detection of non-communicable diseases such as obesity, hypertension, diabetes, and others. It also includes the education against school/family violence, drug consumption, early pregnancy, also offering reproductive health education. This is an essential role of nurses in the schools such as the participants of the interview state:

The problem of drug use is complex, sometimes the student sleep in class, their performance is poor, they are apathetic, don't comply with the rules of the institution. In these cases we call the father, mother, or tutor so that they take part in the issue. Many times the parents deny the reality, and the responsible teachers can't do much, because these are delicate cases. We suggest some things and that's it! Things such as taking them to the doctor, or investigating who are their friends. (P4)

The presence of the nurse will make it easy to care for these cases of preventive student health and for the family to diminish their vulnerability and thus exert an impact in the quality of life of these students and adolescents and their families, and if nurses are in schools, they will be responsible for caring for the health of the public of the school community: student/father/mother/teacher.

The nurses in schools pertinently conduct preventive work imbued within a sustainable work for public health, as the directors say:

It is important to do a coordinated work, give informal speeches to prevent diseases, to cure them. They are few, but we did have some students with cancer, when our students get sick they don't come to the institution or the fathers or mothers have this disease there is abandonment or irregularity in the presences at school. (P7)

The absence of students is incremented by the presence of frequent and not so frequent diseases, which are significant due to the school absence they generate. These diseases can be non-communicable or chronic, that is, long-lasting and generally of slow progression. This highlights the necessity of working in the prevention of communicable and non-communicable diseases, taking into account our own responsibilities when it comes to caring for our health and that of our family.

It is also made clear by the statements that the presence of the nurse offers safety, as the following statements show:

The nurse immediately cares for the students, if anything happens: if they feel headaches, stomach pain, have a cold, bronchi problems, asthma crisis, there is the nurse to care for them, that offers a lot of safety. When I think about a nurse in school, I imagine that their duty will be associated with vaccinations, caring in cases of school accidents, health care... among other tasks. (P5)

Knowledge and competencies are rooted in infancy, and throughout the years it is necessary to constantly work with children and adolescents in order to acquire healthy habits that will positively influence health and life. Health education would have to be an extra subject, which should necessarily be given! Such as physical education, mental and physical health education. Today there are many problems involving children, they have changed, and so have their behavior. (P2)

"[...]" Sometimes the parents give their support, but sometimes they do not, they believe that the school is going to do everything, but we know it's not like that, if the parents do not collaborate in the education, in the formation of their children. We teachers do nothing or do very little. (P3)

The nurse in the school environment, integrated in the Educational Community, is added value, quality value that together with the team of teachers work to normalize the daily life of the child and adolescent, whether they are healthy or have health problems, fomenting healthy life habits in all school population and educational community, such as planned in the bill in congress that incorporates the nursing professional in all educational institutions in a national level in its fourth section about the Designation of a Nursing professional. "It is hereby stated the need to designate at least one Nursing professional in each educational institution, charged with the offering of first aid nursing services and the promotion and prevention of health problems of the students" and its fifth section, regarding the Scope of its application mentions "[...] the group of all regular public and private educational institutions (elementary and high school). When it comes to school nursing, it will be guided by the conduction of a work in a network, through which the integral offering of school health services will be guaranteed and generate participative and quality optimization processes in the offering of services for the student and adolescent"15.

As we see and as we discussed previously, the presence of the nurse in the schools has become a social and health necessity, and the physical presence of the nurse is care, such as the directors mentioned. It has been reported that16-17 in the moment of caring for a person, the physical presence is essential, the body as a minimum space of subjectivities and objectivities of the nurse establishes relations of care with other spaces, other bodies, which intermingle in quotidian life. In this work, the body “nurse” is intermingled with the bodies “student” and “school community”.

Competencies of the school nurse in the articulation of health-education in the daily life of school children and adolescents

Within the competencies of the school nurse is the articulation of health education, in which the school and academic learning and the learning for life, health, and well-being, in the context of the school health programs, are articulated, executed by health professionals, be it from the projection of the health centers, or from the offices of school nurses, emphasizing health promotion, with healthy lifestyles, vaccinations, growth and development, teenage health care, early detection of the most common problems, especially those that are related to health assistance and school performance. The educational directors state that:

Education and health are the backbone of society's development, if the children are healthy, have a good health, they'll perform better, if they have education, they'll be professionals, businesspeople, employees, they'll have their job, make their money and have a good health, they'll be good men and women. Nurses would help keeping their health and improving their lives. (P1)

Health education is very important from an early age, what children learn and what they practice they don't forget, not to mention that they do what the teacher says exactly as said, the younger they are the better, and if the nurse says something it will be the same because they'll see her as their teacher. (P3)

In the daily lives of students, health and education are articulated in healthy school policies, for the improvement of the school environment, with the active participation of students, teachers, families and community, to support science with the awareness of the link that integrates health with education and education with the health of those responsible for the pedagogical process of teaching-learning and living in school. For example, taking obesity into consideration, the Health and Education Secretariats decided alone to restrict the sale of food and drinks in the schools18.

It would be important for other perspectives, in addition to those of health and education, to be present, such as those from neurosciences, endocrinology, nutrition, pedagogy, sociology, anthropology, the direction of health systems, among others; in summation, intersectorality is important. That asks us to rethink the needs and opportunities that characterize the current setting of health promotion, disease prevention and the articulation of these essential pillars of social, cultural and academic development in the school environment. Below are the lines of the directors that similarly state that:

The nurses also have an educational role, since they can give informal speeches, educate the students regarding good hygiene habits, teaching all educational community, fathers, teachers and students. It would also be interesting and important for the institution to conduct researches. Nurses can investigate more than teachers and maybe also feel motivated to investigate issues that interest us as an institution. (P4)

Health personnel are required to: the nurse should be able to coordinate with the teachers so that they can care for the particular cases of each student. (P6)

The nurses' role as educators is evidenced in their work, as the directors suggest. The intersectorality concept goes hand in hand with integration, where the sectors work together and must build a nexus of integration. The presence of nurses in school give them the role of spokespeople for the health sector inside the educational one19.

The correct implantation of a system of management through competencies, allows for: the description of roles; the integration of work teams; the implantation of an organizational culture; the reduction of the generational barrier; the assessment of potential; target based actions; change management.

The proposal for nurses to work is very good because it would result in "integration". We educational centers have a weakness, better yet, the educational sector is forgotten, the budget is small, we teachers have low income, institutional profile is lacking, there is little interdisciplinary work, little creativity, and most of us just wait for orders and follow them. (P2)

Actually the schools should have teachers, nurses, psychologists, nutritionists. There should be a health care office in each school, you can imagine that if it was so the students would have physical, emotional, mental, environmental, social health. (P3)

From the statements of the managers, the school nurse is a spokesperson that is a part of and a link between the education and health sectors, which means that nurses would have a new attribute to their identity20, a word defined as "the group of cultural attributes, which is prioritized over the other sources of meaning". Identity, it is clarified, should not be mistaken for social roles, which are defined as the norms structured by institutions and organizations in society, and in the case of this study, by schools. Identity is built through a process of individualization and self-definition. "[...]"Identities organize meaning, roles organize functions", which means that nursing becomes different as nurses take their professional practices to new spaces.

FINAL CONSIDERATIONS

School nurses, with their competencies in the health promotion of the educational community, raise the following work hypotheses for the meta-analysis conducted and the proposition of competencies for the school nurses: school health will help in the development of a culture of health and well-being, and will help in the modification of social and environmental conditions in the educational community, especially among students: children, adolescents, parents, teachers. The presence of the nurse is expressed in their care, restates the importance of healthy lifestyles, self-image, emotional maturity, mental health, in addition of improving eating habits with health snacks, breakfasts, cleansing of hands, teeth, drinking of sterilized water, as well as helping the school community to change, improve their habits. The school nurse will emphasize the central position of parents, since the habits, beliefs and customs, when it comes to (un)healthy eating habits, are practices that start at home and with the family.

In schools where there is a nurse, the nursing office has an impact in the interdisciplinary articulation: healthy schools and healthy pupils. Competencies of the school nurse in the prevention of diseases in the educational community. The school nurse is the professional with the capabilities to autonomously offer specialized nursing care, within the scope of an educational environment and of an intersectoral and interdisciplinary team. Therefore, the intersectoral role of nurses adds new attributes to their identity. The presence of the nurse in the schools has become a social and health necessity, and the physical presence of the nurse is care.

The school nurse articulates, integrates the space where the life of the students takes place, privileged spaces for education, spaces where one learns to improve their health, their lives. The school nurse cares for the entire educational community population, becoming a permanent nurse. Her practice requires an interdisciplinary, intersectoral, team thought process, that takes into consideration singularities, diversities, integration, collectivity in relations with family, society and environment.

That will allow nursing university colleges to include school health in their syllabuses, as a type of job in the educational sector, and not, as it has been traditionally understood, as an extension of regular health work in the educational field. In the field of assistance, nurses can exercise their competencies as workers in the education sector, offering care to teachers, students, managers and parents. This study also offers an empirical base to the bill currently going through congress, which aims at incorporating a nurse in each public and private school, in order to strengthen the primary health care level and broaden the spaces of professional nursing practice. The study explores the possibility of conducting investigations that answer to the search for new organizational dimensions of health-education, both in public and private spheres, to operationalize nursing work in the first level of health care, through an interdisciplinary and intersectoral health-education action to improve the development, well-being and overall happiness of Peruvian students. Finally, the limitations of this study are its exploratory approach in a place circumscribed to one locality in the Peruvian coast, and the fact that only EI managers were interviewed

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18 Urbina Fuentes M, González Block M. La importancia de los determinantes sociales de la salud en las políticas públicas. 1ra ed. Cuernavaca: Instituto Nacional de Salud Pública (Mx); 2012 [citado 10 oct 2017]. Disponible en: Disponible en: http://medicinaweb.cloudapp.net/observatorio/docs/ss/li/Ss2012_Li_Importancia.pdf . [ Links ]

19 Cunill-Grau N. La intersectorialidad en las nuevas políticas sociales: un acercamiento analítico-conceptual. Gest Polít Pública. 2014[citado 2017 oct 10];23(1):5-46. Disponible en: Disponible en: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S1405-10792014000100001&lng=es&nrm=iso . [ Links ]

20 Castells M. El poder de la identidad en la era de la información. México: Alianza Editorial; 2003. v. 2 [ Links ]

Received: August 05, 2017; Accepted: November 28, 2017

Corresponding author: Flor Marlene Luna Victoria Mori. flor_mlvm@yahoo.com

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