Development of relational competencies in public occupational therapy programs in Brazil¹

Abstract

Introduction  Relational competencies play a central role in the educational processes guided by international propositions for the training and practice of occupational therapists.

Objectives  The presented research aimed to analyze the alignment of the curricula of Brazilian public occupational therapy programs with competency-based pedagogy, to understand the development of relational competencies, and to compare Brazilian curricular content with international propositions regarding these aspects.

Method  A documentary study was carried out on the pedagogical projects of 20 public occupational therapy programs, along with the application of a semi-structured questionnaire to 62 faculty members.

Results  Fifteen projects demonstrate adherence to competency-based pedagogy or the incorporation of its concepts. Relational competencies are part of the professional profile in 15 projects as well, but four of them present a guiding axis regarding the centrality of their development. Most faculty members consider that the program in which they work is guided by this pedagogy and that graduates develop the expected relational competencies, mainly through practical activities. Despite adherence to competency-based pedagogy, the projects show weaknesses, such as the lack of explicit pedagogical affiliation and conceptual imprecision. An initial process of curriculum alignment was identified with the core elements internationally recommended for the development of relationships.

Conclusion  International documents and national curricula need to advance in the composition of relational competencies so that they can reflect the uniqueness of the occupational therapist in understanding engagement in occupations as a tool for social transformation and in promoting inclusion and social participation through relationships established with clients and teams.

Keywords:
Occupational Therapy; Health Knowledge; Attitudes; Practice; Competency-Based Education; Professional Competence; Professional-Patient Relations

Resumo

Introdução  As competências relacionais têm papel central nos processos formativos orientados pelas proposições internacionais para formação e atuação de terapeutas ocupacionais.

Objetivos  A pesquisa apresentada pretendeu analisar o alinhamento dos currículos dos cursos públicos de terapia ocupacional brasileiros com a pedagogia das competências, compreender o desenvolvimento das competências relacionais e comparar os conteúdos curriculares brasileiros com proposições internacionais em relação a tais aspectos.

Método  Realizaram-se o estudo documental dos 20 projetos pedagógicos dos cursos públicos de terapia ocupacional e a aplicação de um questionário semiestruturado com 62 docentes.

Resultados  Quinze projetos demonstram adesão à pedagogia das competências ou incorporação de seus conceitos. As competências relacionais compõem o perfil profissional também de 15 projetos, mas quatro deles apresentam um eixo condutor referente à centralidade do seu desenvolvimento. A maioria dos docentes considera que o curso em que atuam é orientado por essa pedagogia e que os egressos desenvolvem as competências relacionais esperadas, principalmente através das atividades práticas. A despeito da adesão à pedagogia das competências, os projetos apresentam fragilidades, como a não explicitação de filiação pedagógica e a imprecisão conceitual. Verificou-se um processo inicial de alinhamento dos currículos com os pontos centrais preconizados internacionalmente para o desenvolvimento de relações.

Conclusão  Os documentos internacionais e currículos nacionais precisam avançar na composição das competências relacionais, para que consigam contemplar a singularidade do terapeuta ocupacional na compreensão do engajamento em ocupações como ferramenta de transformação social e na promoção de inclusão e participação social a partir das relações estabelecidas com os clientes e equipes.

Palavras-chave:
Terapia Ocupacional; Conhecimentos; Atitudes e Prática em Saúde; Educação Baseada em Competências; Competência Profissional; Relações Profissional-Paciente

Introduction

The reform process of Brazilian undergraduate curricula, initiated in 1996, was guided by the expansion and qualification of the links between education and professional practice and by the replacement of minimum curricula with a competency-based model, given its ability to dialogue with the dynamic nature of the professional profile demanded by society. These propositions were substantiated by the Law of Guidelines and Bases of Education, through the creation of the National Curriculum Guidelines for Undergraduate Courses (Brasil, 1996; Moreira & Dias, 2015).

In the health field, the new care model proposed by the National Curriculum Guidelines adopted as central aspects: the coexistence of biological content with content on psychological, behavioral, social, cultural, ecological, ethical, and legal factors; a focus on health care actions rather than on disease; the coexistence of individual and collective care actions; work in multiprofessional teams; and continuing education (Moreira & Dias, 2015).

The guidelines, developed in the early 2000s, were aligned with the propositions of the World Declaration on Higher Education for the Twenty-First Century, which define that curricula should be based on competency development and on contemporary approaches to professional training. Competency-based education integrates knowledge, skills, and attitudes applicable in real contexts and defines learning objectives that encompass measurable and observable performance characteristics. This approach prepares health professionals for practice oriented towards developing competencies and producing outcomes based on the analysis of the needs of the people served, and enables the integration of the country’s social and health needs with the values of the profession. Higher education in health committed itself to the training of professionals capable of acting with quality and effectiveness in the Unified Health System (SUS), adopting as principles the comprehensiveness of care and teamwork in networks (Organização das Nações Unidas para a Educação, a Ciência e a Cultura, 1998, 2016; Brasil, 2001; Frank et al., 2010; Oliveira, 2011; Gruppen et al., 2012; Jung et al., 2015).

In the case of undergraduate education in occupational therapy, which is the focus of this text, the National Curriculum Guidelines for the undergraduate course in Occupational Therapy, in addition to presenting principles common to health area courses for the organization, development, and evaluation of pedagogical projects, define the specific competencies for occupational therapists (Brasil, 2002).

Competencies can be understood as sets of knowledge, skills, and attitudes mobilized in service of effective action, based on practical experiences and a reflective posture. Knowledge relates to cognitive aspects linked to theoretical frameworks, strategies, information, and procedures. Skills refer to the cognitive, emotional, and psychomotor resources and abilities necessary for performing activities. Attitudes are acquired dispositions that predispose individuals to action, often associated with values – ethical references that guide individual behavior (Perrenoud, 2000; Rué, 2009).

From the dialogical perspective of competency, which proposes the combination of personal attributes with actions aimed at achieving specific results, professional competencies involve the integration of knowledge, skills, and attitudes for performing actions that characterize a profession. They are constituted in the dialogue between educational aspects and the world of work, and respond to guiding standards for professional training and practice (Lima, 2005).

In the international context, in addition to the World Federation of Occupational Therapists (WFOT), countries such as Australia, Canada, the United States, the United Kingdom, and other European nations, starting in the late 1990s, defined competency standards for occupational therapists, establishing areas of general and specific competencies. These standards are expressed in guiding documents that define essential knowledge, skills, and attitudes for professional practice, which must be developed in accordance with ethical, social, legal, and moral commitments (Rodger et al., 2009). These propositions recognize the need to respect national differences and, especially, local contexts, which must integrate three dimensions: the population served, professional profiles, and practice settings. A scoping review that sought to identify the essential areas of competencies in occupational therapy indicated that competency standards should address four areas: professional attitudes; professional communication; ability to work in collaboration with other sectors; and ability to provide quality services to clients (Chun et al., 2020).

The first minimum standards for occupational therapist education date back to 1971 and were revised in 2002 and, more recently, in 2016. Competency-based education has been adopted by the WFOT since 2002 and is seen as a progression in the development of its educational standards. These standards, by proposing convergent guidelines that can provide parameters to guide occupational therapy education, aim to encourage the continuous assurance of quality in professional development and to advance the defense of human rights in the global society. Such standards align with global processes of curricular qualification and unification, exchanges between universities, and student and professional mobility, following internationalization trends (The European Higher Education Area, 1999; Jung et al., 2015; World Federation of Occupational Therapists, 2016).

Jung et al. (2015), in a study that determined how occupational therapy programs approved by WFOT used, implemented, and evaluated competency-based education, indicated that the programs adopted this approach throughout their curricula or in part. The programs have been using the competency standards recommended by WFOT and those defined by their own countries, with some of them undergoing a transition to competency-based education (Jung et al., 2015). This transition requires changes in the pedagogical culture and the curricular structure of the programs, demanding an education that recognizes that students demonstrate competencies at different moments in their training. There must also be a shared understanding of competency-based education and an educational research agenda on this subject among stakeholders, such as professional representative councils and associations, national education councils, faculty members, students, and clients (Hamed et al., 2023).

The new professional identity of the occupational therapist, which has been forming based on the psychosocial paradigm, assumes the centrality of social inclusion and the creation of opportunities for interaction with difference, which occurs through an integrated and systemic view of health and occupation, an understanding of the contexts and living conditions of individuals and communities, political engagement, the defense of human rights, and interprofessional work (Mângia & Barros, 2009; Canadian Interprofessional Health Collaborative, 2010; Souto-Gómez et al., 2023; World Federation of Occupational Therapists, 2016).

This identity configuration highlights the importance of occupational therapy course curricula that adopt an in-depth perspective around the development of relational skills – which can be defined as sets of knowledge, skills and attitudes necessary to establish bonds and build collaborative partnership relationships with clients² and teams –, aimed at carrying out activities that can potentially transform oneself and society. These skills are proposed by World Federation of Occupational Therapists (2016) as soft skills and include communication, interpersonal relationships, emotional sensitivity, political awareness and awareness for transformation.

The study and analysis of seven international documents guiding the training and performance of occupational therapists³, that were part of the doctoral thesis that we briefly present here, verified the centrality attributed to the development of relational skills, since they make up a significant portion of the essential skills proposed in these documents and constitute a central and structuring axis of the training of occupational therapists.

Based on the importance and centrality of developing relational competencies in occupational therapy education, this study aims to: describe and analyze the alignment of undergraduate occupational therapy programs in Brazilian public higher education institutions with competency-based pedagogy; present how relational competencies necessary for constructing the professional profile are defined and developed; and compare Brazilian curricula with international propositions concerning the development and centrality of relational competencies and the professional identity construction.

Method

To conduct this research, the National Curriculum Guidelines for the undergraduate occupational therapy program and international guiding documents for the profession were initially studied, focusing on identifying the adoption of competency-based pedagogy and the development of relational competencies. Subsequently, from August 2016 to August 2018, the stages presented in this article were developed, which included a documentary study of the 20 pedagogical projects of active public Brazilian occupational therapy programs and the application of a semi-structured questionnaire, made available online to faculty members of these programs.

The active public programs during the research period were: Universidade do Estado do Pará (UEPA); Universidade Federal do Pará (UFPA); Universidade Estadual de Ciências da Saúde de Alagoas (UNCISAL); Universidade Federal da Paraíba (UFPB); Universidade Federal de Pernambuco (UFPE); Universidade Federal de Sergipe (UFS); Universidade de Brasília (UnB); Instituto Federal de Educação, Ciência e Tecnologia do Rio de Janeiro (IFRJ); Universidade de São Paulo – campus Ribeirão Preto/SP (USP/RP); Universidade de São Paulo – São Paulo/SP (USP/SP) campus; Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP); Universidade Federal de Minas Gerais (UFMG); Universidade Federal de São Carlos (UFSCar); Universidade Federal de São Paulo (UNIFESP); Universidade Federal do Espírito Santo (UFES); Universidade Federal do Rio de Janeiro (UFRJ); Universidade Federal do Triângulo Mineiro (UFTM); Universidade Federal de Pelotas (UFPEL); Universidade Federal de Santa Maria (UFSM); Universidade Federal do Paraná (UFPR).

To collect the pedagogical projects, contact was made with the program coordinators using data provided by the Ministry of Education (Brasil, 2016), the websites of the higher education institutions, and through the researcher's personal and professional network. The coordinators were informed about the study's objectives, and the submission of the updated pedagogical projects was requested. A direct request to the coordinators was made to ensure the collection of current documents. The contact information of the 339 permanent faculty members was also provided by these coordinators.

The choice of public higher education programs was based on the following factors: the level of organization of the faculty, facilitated by job stability and the academic career; development of teaching, research, and extension projects; presence of pedagogical projects resulting from collective discussion processes; existence of stricto sensu graduate programs; and the fact that public higher education institutions host programs that induce curricular changes, such as the Education through Work for Health Program, and many of the multiprofessional health residency programs.

The analysis of the pedagogical projects was guided by a framework that sought to identify indicators on: presence of aspects of competency-based pedagogy; development of the relational dimension proposed in the graduate profile; and existence of relational competencies in the subjects and other sections of the pedagogical projects, such as general and specific competencies; principles and guidelines of the campus and/or program; course objectives; assessment of learning; and supervised internships. Regarding the subjects, syllabi, objectives, and course contents were analyzed when available. Five pedagogical projects only listed the subject names, their workloads, and prerequisites, or outlined their semester emphases and the mandatory content/themes distributed among them. Another six presented only the syllabi, syllabi with references, or objectives. These information gaps were partially supplemented by the questionnaires applied to the faculty members.

Considering the documents as approximations of reality and also as methodologically developed means of communication, the analysis of these projects provided elements for understanding the development of relational competencies in undergraduate occupational therapy education (Flick, 2009). These documents formalize the theoretical and/or ideal intention of curricular development, potentially reflecting a desired reality, which may not necessarily correspond to the actual teaching process. This limitation was addressed through triangulation with data from the questionnaires answered by the participants, which could more faithfully reflect the daily teaching practice, reveal new dimensions of the studied reality, and more accurately assess the differences – naturally expected – between theory and practice in curricular development (Gibbs, 2009).

The questionnaire applied to the faculty consisted of questions about personal and professional data, in addition to three closed-ended and eight open-ended questions, one of which had three subdivisions. The closed-ended questions addressed the presence of competency-based pedagogy in the curricula and the development of general and relational professional competencies by graduates. The open-ended questions focused on identifying the main competencies for the training and practice of occupational therapists; surveying the relational competencies considered important for this training and practice; the forms of developing relational competencies throughout the program and in the subjects taught by the faculty – strategies, approaches, and theoretical foundations; evaluating the results concerning the development of relational competencies by students; and identifying specific aspects of occupational therapy in the relational competencies listed by the faculty.

The questionnaire was applied through an electronic form created in Google Forms, provided to participants via an access link sent by email. This option was chosen to expand the possibilities of participation from the contacted faculty, as it was believed to favor adherence to the study. Additionally, this tool provides statistics and graphs from the received responses, facilitating the processing of research data for subsequent analysis.

For the proposal and implementation of this study, the assumptions of Resolution 466/12 of the National Health Council, Ministry of Health, which addresses research involving human beings, were observed, especially regarding safeguarding the integrity and rights of participants and the commitment to maximizing benefits while minimizing harm and risks (Brasil, 2012). The research project was approved by the Research Ethics Committee of the Faculty of Medicine of Universidade de São Paulo, February 20, 2017, with the Certificate of Presentation for Ethical Appraisal (CAAE) No. 62878616.8.0000.0065.

The data analysis employed mixed coding approaches – concept-based and data-driven –since the definition of the analysis categories initially stemmed from the guiding questions and research objectives, delineated by studies on competency-based pedagogy and competency standards for occupational therapists, but also relied on data identified through reading and systematizing the documents and faculty reports (Gibbs, 2009).

The data from the pedagogical projects and the responses from the faculty questionnaires were grouped into categories concerning the alignment with competency-based pedagogy and the development of relational competencies in the curricula. From these categories, descriptive syntheses and analytical codes were developed. Comparing the descriptive findings from the closed-ended questions with data from the open-ended questions and the pedagogical projects enriched the data analysis and deepened the understanding of the issues raised by the research (Gibbs, 2009).

Results

Data from pedagogical projects and information provided by faculty members were grouped into categories regarding alignment with competency-based pedagogy and the development of relational competencies in curricula. From these categories, descriptive summaries and analytical codes were developed.

Results from the pedagogical projects of the courses

Alignment of pedagogical projects with competency-based pedagogy

Among the twenty pedagogical projects studied, nine declared adopting competency-based pedagogy, but none provide an objective definition of this approach. The projects from UFPR, UFS, UFSM, USP/RP and UEPA state that the curriculum is organized around the development of competencies. The projects from UNIFESP, UNCISAL, UFTM, and UFPA, although not declaring affiliation, present characteristics indicating the use of this pedagogy, also observed in the first six, such as: curricula structured in axes or modules oriented by the development of professional competencies; professional practice as a guiding axis of the pedagogical project; development of student autonomy and active posture, enabling them to analyze and synthesize their knowledge and develop the competencies necessary for constructing the professional profile; facilitator/mediator role of the faculty in teaching and learning processes; theoretical-practical articulation of knowledge, skills, and techniques throughout the course; and evaluation processes considering cognitive aspects, skills, and attitudes.

In six projects (UFMG, UFSCar, UFPE, UFES, IFRJ, UFRJ), the incorporation of concepts and guidelines from competency-based pedagogy is observed, limited to presenting competencies to be developed; mentioning the acquisition and/or development of knowledge, skills, and attitudes in the training process; and evaluative processes considering the development of competencies. In the remaining five projects (UFPEL, USP/SP, UFPB, UnB, UNESP), these concepts and guidelines are limited to their alignment with the proposals of the National Curriculum Guidelines.

The projects from UFPA, UFTM, and UNIFESP define competencies and/or knowledge, skills, and attitudes. The definitions of competencies found in the UFPA and UFTM projects are similar, stating that their development involves mobilizing and articulating knowledge, skills, and attitudes to propose and perform effective actions demanded by lived practices. The projects also identify concepts related to the development of competencies, such as: competencies, knowledge, skills, attitudes, performance, domains, knowledges, and values.

Presence of relational competencies in defining professional profile

Relational competencies are present in the composition of the professional profile in 15 out of 20 projects and were grouped into five themes: relationships with teams and/or services (competency verified in 14 projects); relational attitudes (verified in 11 projects); relationships with clients (in 7 projects); communication (in 5); and care strategies (3).

The courses from USP/RP, UNIFESP, UFS, UNESP, UFTM, and UFPE affirm the centrality of relational competencies in composing the professional profile. They address the importance of availability for contact with clients, their reality, and occupations; communication and coexistence skills; welcoming, sensitive, and empathetic posture; and establishing dialogical, supportive, and collaborative relationships with clients and teams. The five pedagogical projects that do not reference relational competencies in proposing their profiles are from UnB, UFPA, UFPB, UFSM, and UEPA.

Presence of relational competencies in other topics of pedagogical projects

Except for the professional profile and disciplines, which were analyzed separately due to their importance as indicators of the relational competencies approach, these competencies are most frequently cited in defining specific competencies for occupational therapists, followed by defining guiding principles and fundamental guidelines of campuses and/or courses; learning assessment; development of supervised curricular internships; curricular axes, nuclei, and modules; course objectives; and general competencies.

The projects from UFTM, UFS, UNIFESP, and USP/RP stand out for presenting, in addition to defining the professional profile based on developing relational competencies, their distribution in various components, indicating the existence of a guiding axis regarding the centrality of these competencies in shaping professional training.

The analysis of related competencies found in pedagogical projects involved the identification of principles involved in the development of these competencies in professional training: development of learning based on comprehensive care, ethical commitment to the social needs of individuals and communities, respect for human rights, social responsibility, preservation of cultural values, solidarity, equity, justice and democracy.

This analysis also enabled identifying three categories related to developing relational competencies, presented below.

Guidelines for developing relational competencies

The analysis of the projects and the emphasis given to the development of relational skills allow us to compose a broad framework of these guidelines that show that training aimed at the development of relational skills must be based on overcoming technicality and reductionism and on the search for professional training based on human competence for care, aiming at humanization and qualification of assistance. In this sense, the curricular components must include, in addition to scientific knowledge, knowledge and experiences that develop perception, affection, sensitivity, ethical and aesthetic sense, spirituality and management of emotions and intuition. They show that the teaching and learning processes must allow for openness to dialogue, the exercise of critical and autonomous thinking and coexistence with the plurality of human knowledge and experiences, so that respect for diversity is developed and the possibilities for knowledge production are expanded. Curricular components must also develop practices centered on people and their participation, which enable the experience of horizontal relationships between students and teachers, clients and service professionals, democratic experiences and respect for the balance between individual and collective interests.

This training is also guided by interdisciplinarity and the centrality of relationships in professional development, focusing on the regional and national context and grounded in the principles of Interprofessional Education, Inclusive Education, and Continuing Education.

Knowledge, skills, and attitudes for developing relationships with clients

The projects propose developing partnership, co-participation, and co-responsibility relationships between occupational therapists and clients, characterized by ethics, social justice, citizenship, and human dignity, resulting in projects guided by mutual alignment of needs and expectations, empathetic, clear, accessible, and context-appropriate communication, and adopting conduct respecting professional practice environments.

Developing supportive, collaborative, and inclusive relationships with clients requires occupational therapists to be capable of understanding the socioeconomic and cultural context, comprehending the problems and needs of individuals and communities, acting in conflicting contexts, adjusting strategies, and proposing interventions consistent with their social realities.

Knowledge, skills, and attitudes for developing relationships with teams

The projects state that teaching and learning processes should be directed towards team-based practice and recognize that comprehensive care involves collaborative multiprofessional approaches, based on exchanging experiences and knowledge, respecting diversity, exercising coexistence and dialogue, and collectively developing transformative practices.

They also show that collaborative work requires respecting the differences and limits of various professions, acquiring knowledge about each profession's practice, recognizing role equity in teams, as well as the ability to acknowledge limitations and seek assistance from colleagues. They recommend developing skills for decision-making, communication, management, and leadership.

They assume that producing humanized care involves humanizing relationships among professionals and constructing spaces for listening and welcoming teams, with actions focused on self-care, developing personal skills, and continuing education.

Presence of relational competencies in disciplines

132 disciplines proposing developing relational competencies were identified, with the presence of these competencies most observed in course contents (50.8%) and objectives (47.7%), followed by syllabi (37.9%). The projects from USP/SP, UNIFESP, and UFPE present the highest number of disciplines linked to this development.

These disciplines were grouped into two categories: those directly related to occupational therapy practice, accounting for 44.7% of the total; and those addressing various topics related to the general foundations of the profession, accounting for the remaining 55.3%.

The most frequent themes in the first group were Childhood and Adolescence, Mental Health, Adult Health, Hospital Contexts, and Gerontology. The themes in the second group refer to: care production and the development of relationships with clients; ethics and bioethics; therapeutic activities and resources; health and society; foundations of occupational therapy; management; group approaches; human movement; and professional development.

Results from the information provided by the faculty

Profile of participating faculty

A total of 62 tenured faculty members from Brazilian public occupational therapy programs participated in the study (18.3% of the total who received the questionnaire). The questionnaire was sent to 339 faculty members, and responses were obtained from 19 of the 20 HEIs surveyed.

The average age of participants is 42.5 years. All are occupational therapists, except for one, who is a psychologist. Their average time working in teaching is 11 years and 8 months, ranging from 11 months to 38 years. The largest group (33.9%) has between 5 and 10 years dedicated to teaching. The most frequently cited areas of expertise were the foundations of occupational therapy, child health, mental health, social occupational therapy, and education.

Alignment with competency-based pedagogy and main professional competencies for occupational therapists

Regarding the orientation of the courses, they teach in line with competency-based pedagogy, 40.3% of participants stated this occurs to a large or full extent; 29% said partially; and 30.7% said in some or no aspects.

Most faculty members (59.7%) believe that students develop, to a large extent, the expected professional competencies; 29% believe this occurs partially; and 9.7% believe it happens only in some aspects. The most frequently mentioned competencies were generic skills and attitudes common to all health professionals, mainly related to teamwork, ethical principles, healthcare, communication, decision-making, quality of professional performance, and management. The second most frequently cited group of topics was professional reasoning and the occupational therapy process, particularly in terms of proposing interventions, understanding the relationships of clients with their occupations, identifying needs, and conducting evaluations in occupational therapy. Other notable topics, present in the other two identified groups, refer to knowledge in occupational therapy, with an emphasis on the search for, critical use, production, and dissemination of this knowledge, and on professional integration, especially in diverse fields of practice.

Expected relational competencies, strategies used, and appropriate moments in the course for their development

Regarding the development of expected relational competencies, half of the participants believe this occurs with most graduates; 32.3% believe it occurs with some; and 16.1% report that it happens only in certain aspects.

The relational competencies developed in the disciplines taught by the participants are presented in Table 1, and the strategies they use are detailed in Table 2.

Table 1
Relational skills developed in the disciplines.

Descriptive categories and themes	Number4	Percentage
A) Relational attitudes
Respect	14	22.6%
Empathy	10	16.1%
Ethical stance	09	14.5%
Self-control	05	8%
Cooperation	05	8%
Afection	04	6.4%
Adaptability	04	6.4%
Sensitivity	04	6.4%
Reflective attitude	04	6.4%
Responsibility	04	6.4%
B) Relational skills
Communication	18	29%
Recognition of limits and potentials	11	17.7%
Understanding the context and demands of clients served	08	12.9%
Conflict mediation	07	11.3%
Care practice	04	6.4%
Problem-solving	04	6.4%
Leadership	03	4.8%
C) Relationship with teams and colleagues	24	38.7%
D) Care strategies
Listening	08	12.9%
Reception	06	9.7%
Building bonds	06	9.7%
E) Customer relations	19	30.6%

• Source: own authorship.

Table 2
Strategies used to develop relational skills.

Strategies used	Number	Percentage
A) Bringing people served by the services closer, experiences and carrying out interventions in the field of practice	30	48.3%
B) Training processes for the development of relational skills – feedback to students, dialogued classes and reflective activities	27	43.5%
C) Joint planning and discussion of the interventions	20	32.2%
D) Promoting team activities	13	21%
E) Using groups as a teaching and learning process	12	19.3%
F) Theoretical basis	07	11.3%
G) Participatory methodologies	06	9.7%

• Source: own authorship.

The moments in the courses that faculty members consider most conducive to the development of relational competencies are practical and/or theoretical-practical subjects, mentioned by 62.9% of participants, followed by other subjects specific to occupational therapy, cited by 19.3% of faculty, subjects that address activities or themes related to groups (9.7%), university extension activities (8%), and activities that use active teaching and learning methodologies (8%).

Theoretical foundations used for the development of relational competencies

Thirty-seven participants mentioned theoretical foundations they report using for the development of relational competencies. In the responses of 21 of them, the combination of different fields of knowledge was identified, with 17 of these combining the adoption of frameworks from occupational therapy with those from other fields, mainly the Human Sciences, Education, and Psychology.

Twenty-five faculty members reported adopting the foundational frameworks that guide and underpin the profession, with 19 of them mentioning the following references: propositions from the American Occupational Therapy Association (AOTA) (unspecified); the Occupational Performance Model; Model of Human Occupation; Occupational Therapy in the Social Field and authors who develop themes of occupational justice and occupational inequities; the Framework and Method of Dynamic Occupational Therapy, by Jô Benetton; Occupational Science; Occupational Therapy in the field of culture; Functional Occupational Model; Cognitive Orientation to Daily Occupational Performance (CO-OP); the Code of Ethics and Deontology of Occupational Therapy; and the authors Clare Spackman, Elizabeth Anne Kinsella, Frank Kronemberg, Mariângela Quarentei, Rosemary Hagedorn, and Rui Chamone Jorge.

Eleven participants commented on and justified the theoretical foundations they reported using, and from this, it was identified that the adopted frameworks aim to produce a humanized and interprofessional education that: includes the recognition of students as knowledge producers, based on their repertoires and interests; integrates the affective, practical, and intellectual dimensions of students; promotes the discussion of power dynamics involved in relationships and of social vulnerability and inequality; directs judgments and prejudices toward the construction of practical-reflexive wisdom and attitudes of respect for otherness and human diversity; and is based on the experiences and encounters with the people served and the service teams.

Assessment of the development of relational competencies

The most commonly used forms of assessment by faculty members are the evaluation of performance in practical activities, adopted by 46.8% of the faculty; performance evaluation in activities carried out in the classroom or laboratories (27.4%); self-assessment (16.1%); and evaluation through written and verbal reports (14.5%).

Regarding the types of assessment, although several faculty members indicated the use of summative assessment in conjunction with formative assessment, only the latter was evidenced and described, by twelve faculty members, as the one that prioritizes reflection on learning and is developed through meetings in a processual, dialogical, and day-to-day manner.

Relational competencies and identity construction in occupational therapy

The relational competencies identified as specific to the profession were grouped according to the presence of occupational therapy aspects, from the most generic, developable by any health professional, to the most unique:

1. Generic competencies: Communication; empathy; respect for differences; self-care and care for others; listening skills; conflict resolution; solution development; adaptability; flexibility; self-control; and emotional balance.

2. Competencies with intermediate specificity: Promotion of client autonomy; recognition of values, limits, and capabilities of oneself and others; and understanding of the uniqueness of each individual’s way of life.

3. Competencies specific to occupational therapists: Occupational diagnosis; occupational therapeutic planning; evaluation in occupational therapy; intervention in occupational therapy; understanding of the relationships established by the client in engagement with occupations and in social participation; and recognition of the client’s protagonism in the processes of engagement in occupations and qualification of autonomy.

The discussion of the results will be divided into two parts: discussion of the main findings from the pedagogical projects of the courses and faculty reports; and comparisons of these findings with the propositions of national and international documents that guide the profession.

Discussion of the main results from the pedagogical projects and information provided by faculty

Most of the pedagogical projects refer to the adoption of competence-based pedagogy or the use of its concepts and guidelines. In general, participants are also aligned with this pedagogy, as they recognize that teaching in occupational therapy should be based on the development and improvement of knowledge, skills, and attitudes, and they demonstrate familiarity with the development of competencies in their teaching practice.

Competency-based education is student-centered and enables students to develop the contextualized integration of theoretical and practical attributes and greater awareness of their progress. The knowledge, skills, and attitudes accumulated through the professional training process in the daily routine of services require spaces for analysis and reflection so that students can mobilize and articulate knowledge and face complex situations in the world of work, given the diversity of professionals, clients, care technologies, relationships, and organizational forms of services. Assessment processes related to the development of the expected competencies are also defined (Hamed et al., 2023; Jung et al., 2015).

However, the propositions in the pedagogical projects are distant from international guidelines, with weaknesses similar to those found in the National Curriculum Guidelines, particularly regarding the following aspects: absence or lack of explicit pedagogical affiliation; conceptual imprecision regarding competence-based pedagogy, evidenced by the lack of definitions and the imprecise use of terms such as competencies and skills; lack of definition of central areas from which competencies should be proposed; lack of defined approaches for the development and assessment of competencies (Bregalda & Mângia, 2020).

The synthesis of the pedagogical projects resulted in a diverse set of relational competencies, which included: principles, guidelines, and actions for the development of relational competencies; knowledge, skills, and attitudes for developing relationships with clients and teams; care strategies; methodological strategies for the development of relational competencies; and evaluation processes for the development of relational competencies.

Regarding the relational competencies that faculty members consider they develop with students in the subjects they teach, the most cited refer to relationships established with clients and teams, communication, recognition of potentialities and limits, respect, empathy, ethical principles, listening, and understanding of clients' contexts and demands. These competencies coincide with those considered important for the training of occupational therapists, indicating alignment between what they believe is important and what they manage to achieve in their practice with students.

Among the relational competencies identified as important, faculty members considered 20 as specific to the identity construction of occupational therapists. However, 14 of them were presented in a generic way or had intermediate specificity, as presented in the last section of the Results. It is known that occupational therapists must develop competencies such as communication, empathy, respect for differences, and the promotion of autonomy for the people they serve, in a singular way, with clients and teams. However, since faculty did not demonstrate how the occupational therapist develops these competencies in a singular way, it was not possible to differentiate their development from that carried out by other health professions.

Only six participants pointed out competencies related to the uniqueness of occupational therapy and more clearly configured the new identity of occupational therapy, which adopts as a central objective social inclusion and participation, based on the construction of citizenship, the establishment of collaborative relationships with the people served, and their engagement in meaningful and transformative occupations.

The proposition and implementation of interventions based on experiences in services and territories were mentioned by 30 participants as the most used strategy for developing relational competencies, demonstrating that faculty recognize that it is only possible to learn to relate to people within their life contexts. Occupational therapists, when practicing in the territory, establish contact with various interlocutors and recognize the local history and objective living conditions, which allows for the proposal of actions that develop the potential of individuals and collectives and promote their social inclusion. In this way, occupational therapy knowledge and practices come to be constituted from sociopolitical contextualization, theoretical-conceptual questioning, and the proposition of emancipatory practices (Moreira, 2008; Galheigo et al., 2018).

The significant number of relational competencies identified in the pedagogical projects, particularly in the context of supervised curricular internships, and the fact that 44.7% of the subjects proposing the development of these competencies refer directly to the practice of occupational therapists, reinforce the perception that competencies for relationships are developed in practical activities, especially those that allow greater student autonomy in proposing and implementing interventions with the populations served.

Experiences within service contexts contribute to the professional training of students, due to autonomy, responsibility in problem-solving, shared activities with teams, and the bonds established with workers and users of the services. They also contribute to students' civic education, through the diversity of social, cultural, and environmental issues presented by living with the community, and to the qualification of services, workers, managers, and communities in which students are embedded. Immersion in the community challenges students and faculty to develop a careful perspective on health and illness processes and the social inclusion and exclusion of the populations served, as well as contextualized comprehensive care strategies that dialogue with their social and health needs (Sousa & Cury, 2009; Pulga, 2017).

Starting from the relationships experienced in the reality of the territories and services is a fundamental condition for the development of relational competencies. It is equally important that students are able to identify these experiences, name them, ground them theoretically, and reflect on them, so that they can give them meaning and systematize them. For practical experiences to mobilize the development of relational competencies, teacher mediation and the establishment of partnership relationships between teachers and students are necessary, in order to provide support, security, and space for the experimentation of processes of connection and bond-building with those served, as well as for theoretical-practical articulation, promoting challenges and encouraging a broader perspective on the student’s learning journey (Abrantes & Martins, 2007; Costa et al., 2021).

Although the importance of practice in developing relational competencies is recognized, subjects and activities with little or no practical components also allow for the development and assessment of these competencies, as confirmed by the fact that 55.3% of the subjects proposing these competencies do not have a practical nature.

The theme of teamwork was present in all sections of the pedagogical projects that proposed the development of relational competencies, as well as in all stages of the formative processes for developing these competencies mentioned by faculty. The results obtained from faculty members showed variability in the methods used to develop activities, including working groups among occupational therapy students, participation in multiprofessional actions carried out by service teams, and interprofessional education activities.

However, the challenge remains for programs to develop their curricula based on interprofessional education and work, given its importance in promoting collaborative competencies in professional training, as well as in fostering a teaching practice that is “collaborative, meaningful, interactive, and producer of shared knowledge” (Batista & Batista, 2016, p. 203). Furthermore, interprofessional education, compared to traditional clinical teaching, strengthens professional identity through students' perceived self-efficacy (Souto-Gómez et al., 2023).

Regarding the theoretical foundation for the development of relational competencies, the fact that 40.3% of the participants cited occupational therapy frameworks may indicate that they have based their teaching practice mainly on knowledge produced by the profession, both nationally and internationally. At the same time, participants referred to the importance of integrating other fields of knowledge for the training of occupational therapists competent in building relationships with clients and teams, such as Psychology, Education, Philosophy, and Sociology.

A theoretical study that analyzed national production on the historical-epistemological foundations of occupational therapy, in order to identify trends and regularities, found a movement toward questioning the knowledge and practices of the profession. This questioning, based on contributions from the Human and Social Sciences and Public Health, has enabled occupational therapists to adopt and incorporate a critical-reflective posture (Galheigo et al., 2018).

When addressing the assessment processes used by faculty for the development of relational competencies, the importance of practical activities was again emphasized. It is only possible to assess whether students develop or improve these competencies – and whether they can articulate the theories they have learned with practical proposals and activities – when they meet with the people being served and face their conditions and ways of life, and when they are called to collectively plan and discuss actions within the services and the territory where life happens.

The emphasis on formative assessment in the information provided by faculty and in the pedagogical projects indicates that the development of relational competencies must be assessed in a processual manner, as it requires that faculty and students build partnerships with one another that lead to the establishment of collaborative relationships with those being served.

Formative assessment is directed toward the education and personal and professional development of the student and has as its main function to foster learning. It is practiced continuously on a day-to-day basis, through the observation of the student’s performance in programmed activities and the feedback on this performance, which allows for the identification and improvement of both satisfactory and insufficient aspects, as well as stimulating the student's capacity for reflection and self-assessment (Troncon, 2016).

Comparisons between the findings from pedagogical projects and faculty perspectives with the propositions of national guidelines and international guiding documents

Alignment of general competencies with proposed relational competencies

Comparing the results from the faculty questionnaire on the professional competencies expected of graduates with the findings from international guiding documents for the profession, it was observed that they are aligned in terms of the importance of competencies related to professional reasoning and the occupational therapeutic process, as well as the production and use of knowledge in occupational therapy.

The information provided by faculty on the development of relational competencies aligns with the propositions in international guiding documents and the pedagogical projects of national programs, regarding competencies for teamwork, communication skills, ethical commitment to the social needs of individuals and groups served, understanding of clients' contexts, conflict mediation, and attitudes of empathy and respect for diversity and difference.

Faculty responses and pedagogical projects demonstrated advances in discourse compared to the National Curriculum Guidelines, which include few relational competencies among the general and specific competencies recommended. In general, the synthesis of relational competencies identified in the pedagogical projects showed progress compared to the synthesis of these competencies in international guiding documents and faculty discourse. Although it obviously does not reflect the reality of all projects, this synthesis covers the competencies related to themes identified in the documents and faculty discourse, and goes further by presenting a greater diversity of competencies in each theme and addressing principles, guidelines, and actions for the development of relational competencies.

Centrality of relational competencies

In the faculty responses, the importance attributed to relational competencies is evident in the diversity and quality of the competencies and strategies mentioned, mainly related to teamwork, communication skills, understanding of clients’ contexts, conflict mediation, empathy, and respect for diversity and difference.

However, this importance still falls short of the centrality of relational competencies recommended by international documents, as can be inferred from the fact that they were mentioned in a limited way by faculty when asked about the main professional competencies for the training and practice of occupational therapists.

In general, the programs have signaled the importance of relational competencies, with variability in the ways and degrees to which they adopt their centrality. Only four pedagogical projects – those from UNIFESP, UFS, USP/RP, and UFTM – present the development of these competencies as central throughout their structure, approaching the centrality recommended by international guiding documents.

Thus, the comparison between the synthesis of relational competencies identified in the pedagogical projects, faculty responses, and guiding documents shows that Brazilian curricula demonstrate progress in the centrality of relational competencies relative to the National Curriculum Guidelines and are in the process of aligning with the key points recommended internationally for the development of relationships.

Adoption of the psychosocial paradigm and the identity construction of occupational therapy

Regarding the uniqueness of the profession, the responses from faculty related to professional reasoning and the occupational therapeutic process align with the strong identity construction of the profession observed in guiding documents, particularly the emphasis on the relationship between the client, their occupations, and their contexts; the relationship of occupational therapists with the occupations of the individuals served; and the influence of environmental factors and life contexts on the occupational performance and social participation of these individuals.

On the other hand, the mention of generic skills and attitudes, which may be shared with other health professions, indicates faculty awareness that occupational therapists must be competent to perform actions common to all team members in services, a point also observed in international documents. However, these documents advance by attributing greater specificity of occupational therapy to the competencies common to all professions, individualizing the ways in which occupational therapists can develop them, which is scarcely observed in faculty discourse.

It was found that faculty responses and the pedagogical projects of the courses point to the profession's paradigmatic transition from the biomedical model to the psychosocial model, already well advanced in guiding documents, where a consistent adoption of the latter paradigm is observed. Pedagogical projects and faculty refer to adopting professional actions centered on valuing abilities and potentialities, engaging in occupations, and promoting inclusion and social participation of the individuals served, rather than focusing on disabilities, dysfunctions, or diseases, extending to collectives, contexts, services, and policies involved.

The results from the faculty questionnaire and the projects show progress in this paradigmatic transition compared to the propositions of the National Curriculum Guidelines, demonstrating greater clarity in constructing the professional identity of the occupational therapist in the specific competencies expected for graduates of the courses.

This paradigmatic transition supporting the construction of the profession's identity proposes a set of technologies no longer solely aimed at alleviating disabilities, enhancing communication, or improving motor patterns. It involves adopting a paradigm of social inclusion based on client participation and satisfaction with their occupational performance, as they can develop desired occupations in everyday life settings. This contrasts entirely with the biomedical and normalizing approach present in the historical tradition of the profession's development, where the therapeutic goal is to bring the person as close as possible to normality and mask their differences. This paradigmatic shift enables the creation of opportunities for collective coexistence with difference and for the social inclusion of individuals considered different, respecting the diversity of forms and ways of life. Moreover, this perspective demands that the social context create effective conditions to reduce barriers and promote access and social participation for all, recognizing that it is the context that imposes obstacles and barriers to difference (Organização Mundial da Saúde, 2003; Mângia & Barros, 2009; Moreira, 2022).

Finally, comparing the relational competencies present in guiding documents, pedagogical projects, and faculty responses with the general propositions presented by guiding documents, it is evident that curricula, national guidelines, and the documents themselves need to advance in composing the proposed relational competencies to encompass the occupational therapy identity construction with the same consistency observed in defining general professional competencies.

This professional identity has been historically constructed from questioning the exclusion of difference and the institutional masking of social issues and deinstitutionalization movements. It requires the agency of new technologies and care strategies in occupational therapists' practices, preferably developed in the territories where people live and circulate, considered as space-time for bonds and development of potentialities, intertwining daily needs with collective sociocultural reality (Moreira, 2008, 2022; Mângia & Barros, 2009).

Conclusion

The presented research enabled a comprehensive characterization of the pedagogical projects of the courses and an understanding of the perspectives of faculty members regarding national and international guidelines that establish competency standards for occupational therapists. Furthermore, it allowed for the systematization of identified relational competencies, indicated curricular trends in proposing these competencies, and produced reflections and discussions about their development and the profession's identity construction in Brazilian public courses.

Most of the studied pedagogical projects and the opinions of participating faculty indicate the courses' affiliation with the competency-based pedagogy or mention characteristics that allow concluding its adoption. However, the research confirmed the conceptual fragility regarding this pedagogy, as well as the lack of definition of central areas and approaches from which competencies and/or training should be proposed, developed, and evaluated. The applied questionnaire did not allow for deepening the level of appropriation of this pedagogy by faculty, but their responses evidenced familiarity with using competencies in teaching and learning processes, mainly concerning skills and attitudes developed by students.

The syntheses of relational competencies identified in the pedagogical projects and faculty responses allow verifying, beyond the initial process of aligning Brazilian curricula with the central points internationally recommended for developing relational competencies, significant advances compared to the National Curriculum Guidelines. However, this does not allow generalizing this reality to all Brazilian courses, as this centrality is not observed in most of our curricula. In general, courses have signaled the importance of relational competencies, but only four pedagogical projects, notably that of UNIFESP, present the development of these competencies as central throughout their structure.

This fact points to the need for systematization of these competencies in the new Guidelines and in the studies and publications of the profession, which may have implications for formulating and reformulating the pedagogical projects of Brazilian occupational therapy courses, aiming to continue advancing towards the centrality of these competencies.

The information provided by faculty and Brazilian pedagogical projects point to the profession's paradigmatic transition from the biomedical model to the psychosocial model, which underpins a professional identity already quite consistent in international guiding documents, based on promoting inclusion and social participation of individuals served by the profession. This points to a process of aligning Brazilian occupational therapy courses with globally proposed competency standards and preparing for new processes of international accreditation, exchanges, and student and professional mobility.

Finally, international guiding documents, Brazilian pedagogical projects, and faculty responses need to advance in constructing the occupational therapy identity in composing the proposed relational competencies, so they can encompass and appropriate, with the same consistency as the general propositions for competencies, the uniqueness of the occupational therapist in defending human rights, understanding engagement in occupations as a tool for social transformation, and promoting inclusion and social participation through relationships established with clients and teams.

• 1
  The manuscript originated from the doctoral research entitled “Undergraduate training in occupational therapy and development of relational skills: study of the curricula of public courses in Brazil”, developed by the main author.
• 2
  The term “client” can refer to an individual, family, groups, communities, organizations and government (World Federation of Occupational Therapists, 2016). For conceptual standardization of this text, it was decided to adopt the term “client” and the expression “people served by occupational therapy”, replacing the terms “user”, “patient” and similar.
• 3
  The documents analyzed were: Entry Level Competencies for Occupational Therapists (World Federation of Occupational Therapists, 2008); Reference Poitns for the Design and Delivery of Degree Programmes in Occupational Therapy (European Network of Occupational Therapy in Higher Education, 2008); Australian Minimum Competency Standarts for New Graduate Occupational Therapists (Australian Association of Occupational Therapists, 2010); Standarts for Continuing Competence (American Occupational Therapy Association, 2010); Essential Competencies of Practice for Occupational Therapists in Canada (Association of Canadian Occupational Therapy Regulatory Organizations, 2011); Entry Level Occupational Therapy Core Knowledge and Practice Skills (College of Occupational Therapists of United Kingdom, 2016); Minimum standards for the education of occupational therapists (World Federation of Occupational Therapists, 2016).
• 4
  The number in Tables 1 and 2 corresponds to the participants who listed competencies within each thematic category. Participants who listed more than one competency per category were only counted once in each category.
• How to cite:
  Bregalda, M. M. & Mângia, E. F. (2025). Development of relational competencies in public occupational therapy programs in Brazil. Cadernos Brasileiros de Terapia Ocupacional, 33, e3867. https://doi.org/10.1590/2526-8910.ctoAO398338672

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Edited by

• Section editor
  Profa. Dra. Késia Maria Maximiano de Melo

Publication Dates

• Publication in this collection
  05 Sept 2025
• Date of issue
  2025

History

• Received
  04 June 2024
• Reviewed
  19 June 2024
• Accepted
  03 Apr 2025