Dialogic approach to competence: assumptions and methodological path for the construction of profiles in the health area

This theoretical investigation presents the dialogic approach to competence, its principles, and methods for the construction of professional profiles. Unlike conceptions that focus on isolated elements of competence, the dialogic approach is based on an integrative framework and proposes areas of competence that characterize core and field in professional practice. This approach recognizes the existence of different views on professional competence that must be analyzed and discussed. A set of strategies, devices, and methods capable of triangulating these views and systematizing professional activities is presented. The competent profile, built as a meta point of view, translates contextualized combinations of knowledge, skills, attitudes, and values that express excellence in professional performance, with a view to training, certification, and continuing education of health professionals. The text analyzes the coherence between practices systematized in the way proposed here and the development of entrustable professional activities. between education and work enhances: (i) the relationships between academia and work, which increases the attention given to social needs; (ii) the use of best practices and scientific evidence to reorganize the work and the educational processes; (iii) the agreements that foster exchange programs between students, teachers and workers from different countries and institutions; (iv) the organization of people management processes based on competency profiles; (v) the development of new tools and criteria for the certification of competence.

highlights that the prioritization and the importance attributed to certain elements of competence define theoretical frameworks that support different models. The model targeted at the adjustment of competency profiles to market demands can be categorized into two types: conductivist and functionalist. In the conductivist model, also called behaviorist model, the theoretical framework values the acquisition of predominantly cognitive attributes, assuming that those who know are capable of doing. In the functionalist model, great value is placed on performance of tasks and obtention of results in and out of organizations, focusing on professional functions and on the systemic approach to work 4,5 .
The model targeted at the transformation of work processes, governed by the constructivist and critical-emancipatory perspectives, focuses on the forms and means through which subjects contribute, by the appropriation of their profession or occupation, to reproduce or transform work processes. The constructivist model is interested in how professional practices can be transformed and in the role played by professionals in the reproduction and transformation of their professions or occupations 1 . The critical-emancipatory matrix seeks to articulate the needs of workers and of work processes committed to excellence in processes and outcomes, aiming to organize educational initiatives targeted at an amplified professional education [5][6][7][8] .
The present theoretical investigation aims to introduce the dialogic approach to competence, its principles and methods, in order to establish coherence between processes of training, assessment and certification of competence by means of certifiable professional activities 20 . Interface (Botucatu) https://doi.org/10.1590/Interface.220155

Theoretical framework of competence in the area of health
In view of the emerging challenges in the training and continuing education of health professionals for the 21 st century, the atomistic frameworks of competence, grounded on discrete and verifiable behavioral objectives, have proved to be insufficient due to the complexity and uncertainty experienced in collective work processes related to healthcare.
Fraser and Greenhalgh 21 , also opposing the atomistic view of competence, defend, with their concept of capability, an integrated view based on the idea of competence as a meta-capacity for mobilizing different attributes in singular and changing organizations and contexts. Thus, the definition of competency profiles require a better understanding and differentiated practices regarding demographic and epidemiological changes in societies, healthcare in chronic conditions, interprofessional work, organization of integrated healthcare networks, and ethical actions committed to improving quality and security.
In a publication in "The Lancet Commission on Education of Health Professionals for the 21 st Century", Frenk 22 highlights that: [...] new infectious, environmental, and behavioural risks, at a time of rapid demographic and epidemiological transitions, threaten health security of all. [...] Professional education has not kept pace with these challenges, largely because of fragmented and static curricula [that express] the mismatch of profiles to patient and population needs; poor teamwork; ... narrow technical focus without broader contextual understanding; episodic encounters rather than continuous care; predominant hospital orientation at the expense of primary care; ... and weak leadership to improve health-system performance 22 . (p. 1923) Thus, the concept of competence, according to an integrated and situational framework of the elements that constitute it, supposes inference based on the action of subjects, who mobilize and combine resources (knowledge, know-how or skills and attitudes), adjusted and pertinent to context (relationships, documents, information, accessibility and others), to achieve effective performance in the face of challenges 1,16 .
In health education, such conception aims to overcome technicism, memorization and poor contextualization of knowledge, as well as fragmentation between activities/actions and attributes/capacities. At the same time, it aims to enhance the critical analysis of data and information, theory-practice integration, complex thought, production of creative, singular and contextualized interventions targeted at the needs of patients/caregivers/ families, collaborative teamwork, and commitment to improving care quality and security. According to Gòmez 23 : […] competent human behavior in complex, changing, open and uncertain contexts is necessarily reflective, including mechanical and routine skills, but always governed by a reflective mind that says when, where and how to use such routines because they are adequate to that professional's way of understanding the peculiarities of the situation, problem or context 23 . (p. 80) In addition to being situational and combining resources, the holistic conception requires a clear distinction between the capacities that can be mobilized -such as knowledge, skills and attitudes -and competence per se, which presupposes decisionmaking and initiative in the face of a challenge. Thus, competence is expressed by means of actions, being the result of the articulation and combination of a set of resources, according to context and to the best scientific practices.
In Brazil, the conception of competence started to be advocated in health education with the publication of the National Curricular Guidelines (DCN) for Undergraduate Programs at the beginning of the 21 st century 24 . The DCN for Undergraduate Medicine Programs 25 , published in 2014, advanced in relation to the previous edition by considering capacities or skills as constituent elements of competence; therefore, competence is not limited to the possession or to the disjoint or compartmentalized verification of such elements. According to Deluiz 9 : […] it is necessary to highlight the conceptual confusion between competencies and skills. If, by definition, competencies are mental operations that articulate and mobilize knowledge, skills and values, skills would be constituent elements of competencies. Identifying competencies, skills and technological bases in the reference matrices of the professional areas in a separate, fragmented way is, therefore, a theoretical-methodological incoherence. (p. 5)

The dialogic approach
The evolution of the systems sciences, which emerged in the middle of the 20 th century, especially with ecology and earth science, has promoted the construction of more integrative explanatory systems about reality, enabling the introduction of innovative elements in the Cartesian conception of science. This innovation counterpoints the positivistic approach, which advocates isolating and compartmentalizing the social processes in order to study them 26,27 .
According to Morin 27 , the compartmentalized production of knowledge divided into disciplines is insufficient to deal with the whole, because new phenomena emerge in it due to associations between its parts, and other phenomena are inhibited by the presence of these very associations.
Systemic thinking, together with the ideas of order-disorder-organization, stimulated the emergence of a new approach to knowledge production according to the dialogic principle and to complex thought 28 . Thus, the complexity theory allies itself simultaneously with analytical thinking, which focuses on the specific exploration of each part, and systemic thinking, which focuses on the investigation of the interactions and effects generated by the simultaneous change of variables in social processes 28,29 .
Dialogism, as a principle, shifts the meaning from contradiction between differences to dialog between differences, and is defined as a complex association -complementary/ concurrent/antagonistic -of logics inherent in the existence of a phenomenon, according to a spiral, retroactive-recursive, transforming movement [26][27][28][29][30] .
Morin 27 uses the notion of dialog as an interaction between distinct viewpoints on knowledge, in an active cycle where relationship and movement are considered permanent states between the different elements or components of a system. In addition to the specificities and differences of each element, he recognizes the recursive and complementary relationship that is instituted, for example, between analysis-synthesis; disciplineinterdisciplinarity; objectivity-subjectivity; separability-inseparability; certainty-uncertainty; order-disorder; and so on. In this perspective, relationships that seem to be contradictory are understood as potentially complementary.
In philosophy, dialogism proposes that contradictions be recognized so that it is possible to formulate a concept that links different perspectives that are apparently separated, with no element being submitted to the other. According to Sánchez 29 : […] the dialogic process [is a] term that Morin takes from Föerster (1962), [and which differs from the dialectical process when the latter] "recognizes two logically exclusive propositions [...] and considers that contradiction is a transitory state to be overcome in the crisis" 29 . (p. 173) In the dialogic approach, the generation of the new does not occur through movements to overcome the contradiction; rather, it happens through a continuous, complementary and recursive interaction between the components of a system, and it can be, at the same time, antagonistic and concurrent 27,28 . Having highlighted this distinction, we can identify in dialogic thinking the presence of various elements of dialectics, such as the concepts of historicity and social construction, and the notions of process and transformation.
Dialogism also takes into account the principles of dialectics related to (i) the unity and struggle of opposites, recognizing that everything is related; (ii) movement, as everything undergoes transformations; and (iii) contradiction, characterized by the negation of negation 31 . It differs in the interpretation of synthesis, which, instead of representing a rupture or an overcoming of both the thesis and the antithesis, seeks, in the simultaneity of the contradictions, to construct a meta point of view in relation to reality, phenomena and knowledge 26,28 .
In science, the dialogic principle implies the articulation of distinct logics in an open rationality -translated by an organizing and critical force that proposes a mediation between rationality and the meaning of rational to the human being 27,28 .
Thus, the production of knowledge, contextualized by history and accumulations/ challenges in a scientific and social field, reveals possible and distinct logics that affect object(s) and subject(s), in a dynamic, continuous and relational perspective. It encompasses, in a complementary way, systemic and analytical thinking, so that separation-inseparability co-exists in an investigation that focuses on the general and the singular, placing them in context. Therefore, the dialogic approach proposes the reorganization of knowledge in order to value complementarity, for example, in the relationships between science-art; objective-subjective; abstract-sensitive; mutation-conservation; individual-collective; male-female; health-disease; and education-work, among others [27][28][29][30] . Philosophically speaking, dialogic reasoning proposes the construction of a meta point of view when it comes to reality, phenomena and knowledge [27][28][29][30] . It presents synthesis as a fusion of point and counterpoint 27 .
Morin 27 uses the concept of dialog as the interaction between distinct points of view on knowledge. As in a spiral, the movement and relationship between the elements of a system are permanently considered in a space where dialogic relationships prevail.
In this context, the dialogic approach to competence grounded on the integrative or holistic framework is characterized: (i) in its philosophical dimension, by the complementarity of its constituent elements, even when apparently contradictory, with no element being submitted to the other, enabling the construction of a meta point of view; and (ii) in its technical-scientific dimension, by the identification and articulation of the logics and rationalities that support and characterize areas of competence and by the organization of these areas according to professional activities that define and express work processes and best practices.
The thesis defended here is that the dialogic approach to the construction of competency profiles orients the profile to social needs and favors the transformation and qualification of work processes. Furthermore, it reveals best practices for training and promotes certification by means of entrustable professional activities.

Assumptions for the construction of competency profiles according to the dialogic approach
According to the dialogic approach, the construction of competency profiles must recognize the complex relationship between the spheres of education and work in a given society, based on the distinct views of different social actors.
Concerning the social-historical dimension of the construction of these profiles, the dialogic approach requires the disclosure of the political, social, economic and historical tensions that outline distinct views of the actions and attributes that allegedly constitute a competent professional practice. To achieve this, views related to work, education, regulation and professional certification are considered parties interested in the definition of competency profiles.
With regard to work, the dialogic approach views praxis as a fertile field for the production of new knowledge, including the perspectives of customers/users, managers and professionals.
As for education, the dialogic approach aims at the articulated development of all the elements that constitute competence and connects professional capacities with the necessary action in a given context, integrating work and education in mutual transformation processes.
Integration between theory and practice, reason and emotion, as well as the development of complex thought and of contextualized and entrustable professional activities, are the main contributions of the dialogic approach in the sphere of education.
Reflective, creative and critical capacities, as well as metacognition, are highlighted as attributes in the new professional profiles, considering the importance of the unforeseen and uncertain in the real world, together with capacities to deal with the emergence of conflicts inherent in the interaction with others, be they customers/users or professional teams. Thus, participation in the collective work of multiprofessional teams, the permanent construction of new knowledge, and the culture of improvement in processes and products have expanded and qualified the professionals' field of work beyond the core that characterizes a certain professional training. This expansion is clearly visible in the construction of profiles according to the dialogic approach to competence, favoring professional management and certification processes.

Methodological path of the dialogic approach
The analysis and discussion of the methodological path used in the study are presented based on the stages and devices that were employed, highlighting the intentionality and the products that were obtained (Figure 1).

Recommenders -relevant social actors who recommend professionals considered competent
Social actors involved and interested in the construction of the competency profile of a profession or occupation, such as educational institutions, associations and representative corporations, regulatory agencies and employers, representatives of different segments of society directly involved with the profession/occupation in question, must be mapped and engaged in the process. The weight of the representation of each actor or social segment must be clarified and justified, and their different contexts of professional activity, as well as local and regional specificities, must be taken into account in the selection of recommenders.
The mapping of social actors interested in the definition of competence originates a set of recommenders that is responsible for identifying professionals who, according to their perspective, work in a competent way. In relation to the conception of competence, no interference or influence should be introduced, in order to ensure distinct views. At the same time, they also recommend professionals for an advisory board that will validate, remotely, the obtained results.

Professionals recommended as competent
The recommendation of professionals considered competent to participate in a workshop for the investigation of practices is a crucial stage to the definition of competency profiles. The inclusion criteria must be previously agreed with the recommenders. For example, the professional must: (i) have an undergraduate degree in the career in question or work in the investigated function; (ii) be considered a competent professional and a role model for the education of future professionals; (iii) have current practice in the area, in contexts that represent work spaces existing in the country; (iv) have their working day and predominant income composition formed by their professional practice in the area in question; (vi) be available to register their experience and participate in a workshop for the investigation of practices; (vii) accept the recommendation and sign a consent document, agreeing with the possible dissemination of the produced material.
Examples of exclusion criteria: being a newly graduated student or a retired professional; not being available to participate in the workshop or to fill in the data collection instruments. Interface (Botucatu) https://doi.org/10.1590/Interface.220155 The professionals recommended by the recommenders as competent may be asked to produce one or more of the following instruments: (i) a spreadsheet that describes a typical working week; (ii) a report on a critical incident in their professional life that represented an unexpected challenge. The outcome of the episode may be satisfactory or unsatisfactory 32 ; (iii) a reflective narrative about their own professional performance; (iv) a report on their professional trajectory.
According to Zarifian 33 , the notion of critical incident/event amplifies the utilized modeling, including the mobilization of capacities to solve new or unexpected work situations that emerge from unpredicted events. These critical incidents, regardless of the outcome, produce tension and challenge the established work processes, transcending the capacities that are already known or which are part of the routine. The way in which the professionals deal with those situations and the repercussions they bring to the instituted work processes can reveal the learning progress of the organizations and their openness to the continuing education of the graduated professionals.
LeBoterf 18 argues that competence is produced in the confluence of three axes: biography, which reflects the process of socialization and constitution of the subject, educational background, and professional experience. Thus, the subjective dimension has a significant value in this construction, although it is little considered by the conductivist and functionalist models. Therefore, the workshop participants' reflective narrative about their professional practice and the report on their professional trajectory give visibility and voice to their singular experiences of competence construction. This enables to clarify workers' interests and values in this construction and the repercussions of their interaction with other professionals, teams and organizations, in complex, open and uncertain contexts that characterize collective work processes of healthcare.
The reports or narratives can also be collected by means of interviews or focus groups 34 . The authorship of such information must be treated in a confidential way, and the analysis of these data must precede and contextualize the workshop for the investigation of practices.
The interpretation of the consolidated data can be performed by means of content analysis, in its thematic modality 35 , triangulated 36 with results from the workshop 37,38 , revealing, invariably, aspects that do not receive much attention in professional training processes.

Workshop for the investigation of practices
In the interaction between participants and facilitators, the symbolic material -expressed verbally and non-verbally -and subjective and interpersonal aspects must be observed and registered during the workshop. Qualitative techniques should be employed in the process, following hermeneutical-dialectical principles that take into account the context, style of thought 39 , and interactions between discourse and actions and between the latter and underlying values and interests.
For the investigation of practices, two methods adapted to the dialogic principles can be employed. The first is functional analysis 5,11,13,40 , modified in order to reveal the actions carried out by the workshop participants. Such actions must characterize a productive activity, as well as the processes that express the interrelations between such activities, considering the organizational and systemic context and the values attributed to the actions by the participants. The second method enables to analyze the nature and grouping of actions and work processes according to the predominant rationalities, by analyzing the type of problem or challenge that needs to be faced 1,5,[40][41][42][43] .
The process of application of these two methods should guarantee that all actors involved are heard and all the presented ideas and values are considered. In addition, it should ensure the expression of diverse practices in different contexts of professional action; identification of complementary, concurrent and antagonistic aspects in the reported practices; integration between capacities, actions, context and excellence criteria; and articulation between the perspectives of work, academia and social needs.
Based on guiding questions to explore professional practices, the participants are invited to write, in a synthetic way, their main activities in the daily routine of work, which they recognize as the practices that produce the best results ( Figure 2).
The activities and the results are presented to the group, clarified, contextualized and justified. This analysis enables the emergence of the subjective dimension, by means of the expression and discussion of the workshop participants' values, desires and interests.
Meaning units are formed according to the affinity of the presented ideas, and this advances to the constitution of units of professional practices, also called key actions or key activities. To each key action, the complementary, concurrent and antagonistic aspects of the participants' praxis are identified and analyzed, and a new synthesis is produced, grounded on best practices. The work processes characterized by the relationship between key actions must be grounded on a style of thought 39 that supports a certain type of intervention. The performances that shape and detail key actions must be expressed by means of action verbs, according to context and excellence criteria. The predominance of a certain rationality in the identified processes -for example, the clinical-epidemiological reasoning -defines the areas of competence.
The set of areas of competence translates a professional profile that contains: (i) the sphere or professional field; (ii) the professional core; (iii) the predominant rationalities or styles of thought; and (iv) the key actions that express the work processes and shape an area of competence. Although they have specificities due to the key actions and associated rationalities, the areas of competence interpenetrate each other and articulate with one another in the professional practice.

Systematization of the competency profile
The findings of the workshop for the investigation of practices must be triangulated with the other instruments produced in data collection, considering the identity, purposes, attributed meanings, trajectories, and interrelations of professional practices in their dynamics, in order to express the processes and organization of professional action in certain contexts.
The concepts of core and field that support the organization of the competency profile in areas of competence are based on an adaptation performed by Campos 44 in relation to the concepts of "field" and "corpus", developed by Bourdieu (1983). According to Campos 44 : Thus, the area that represents the professional core characterizes and distinguishes the specific activities of a certain career or function. The activities belonging to the areas of competence that represent the field can be performed by professionals from different careers. To each area, the key actions or professional activities must be defined, characterized and contextualized.

Validation of the competency profile
The Delphi 45 technique can be used to validate the preliminary synthesis of the competency profile. It can be applied remotely, through an electronic medium. The validation processes must have at least two rounds of appreciation: the first performed by the workshop participants themselves and the second by the advisory board.
All the elements that compose the profile must be validated according to the scale: I totally disagree, I partially disagree, I partially agree, and I totally agree. The participants should add comments, particularly when there are disagreements, and include activities that are lacking.

Applications and challenges in the construction of competency profiles
Considering that a competency profile can guide the education, professional certification and/or people management processes, including recruitment, selection, development, and performance evaluation 3 , choosing the dialogic approach implies a series of technical-political actions and the attribution of value, by those involved, to the dialog between different views and segments of society.
Among the main challenges, we highlight the selection of recommenders and recommended professionals and the conduction of the workshop for the investigation of practices. In the selection of recommenders, guaranteeing a diversity of perspectives is quite challenging. The selection of recommended professionals, in turn, requires compliance with the inclusion and exclusion criteria. The conduction of the investigation workshop demands skills to construct meta points of view that include and discuss social needs, different practices, and distinct conceptions of what it means to be competent.
The main application of the competency profile is the guidance of training and professional certification processes. Based on activities that represent the work that must be carried out, contents, disciplines and triggers can be selected, and curricular activities can be organized. This type of curriculum uses triggers that favor the articulated and contextualized development of the required capacities, promoting connections between cognition, skills, attitudes, and professional activities of the competency profile. Excellence criteria, considering the practice of beginner or advanced students, competent, proficient and specialist professionals 46 , must also be established, as well as the performances/practices that must be supervised.
Broadening the dialog between education and work enhances: (i) the relationships between academia and work, which increases the attention given to social needs; (ii) the use of best practices and scientific evidence to reorganize the work and the educational processes; (iii) the agreements that foster exchange programs between students, teachers and workers from different countries and institutions; (iv) the organization of people management processes based on competency profiles; (v) the development of new tools and criteria for the certification of competence.

Applications and challenges in the assessment, regulation and certification of competence
In the sphere of regulation and certification, the dialogic approach must encompass competence certification processes that express the socially recognized knowledge, according to practice that is considered competent. With the disclosure of this knowledge, learning is able to leave the private sphere, gain visibility 15 and enter the public sphere. This takes certification and accreditation to the field of conflicts of interest, power relations, and power hierarchies in society 1,16 . In this context, the accreditation of educational institutions and professional certification must respond to a new social commitment, defined not only by the legitimacy of specialists, but also by the dialog between them and different actors and social partners 1,16 .
Thus, assessment in the dialogic approach implies recognizing these differences and agreeing on the criteria that should give credibility and reliability to education, assessment and professional practice.
The instruments for this type of assessment must equally consider some specificities, such as the validity of the content of contextualized situations; the analysis, without subordination, of the elements that constitute competence; the degree of entrustability; and the previous and clear definition of the assessment criteria that use the desired professional profile as reference.
Regarding the assessment of competence according to the dialogic approach, an integrated analysis of the areas of competence and of key actions or activities must be performed. Based on a critical evaluation of the fragmentation of assessment processes, ten Cate 20 proposed the concept of Entrustable Professional Activities (EPA). Represented as units of professional practices that the apprentice can be entrusted with and execute without supervision, EPA can be used to guide assessment based on real-world practice. These activities are a critical part of professional work that can be entrusted to someone who has shown the necessary capacities to perform, successfully, a set of professional activities 20,47-49 . The EPA are descriptors of professional work and a translation of competence. They can be used to organize a competency-based curriculum and teachinglearning processes, considering the integration of cognitive, psychomotor and attitudinal elements of competence, according to context. According to ten Cate 49 and Mulder 3 , the EPA build bridges between competency-based education theory and practice.
In light of the dialogic approach to competence, the concept of EPA is coherent with that of key actions and can be applied to other areas of competence, beyond the clinical area. It is essentially due to such coherence that the performances that characterize the competency profile in the model proposed here are expressed by means of observable action verbs, favoring the establishment of EPA in assessment and professional certification processes. Interface (Botucatu) https://doi.org/10.1590/Interface.220155

Final remarks
The competent performance of health professionals, which supposes recognition, legitimacy and certification for a socially responsible performance, remains an emerging field for investigations, particularly due to specificities in the interaction between health professionals and between them and patients, organizations and society. The construction of responses to health needs, in view of rapid technological, scientific, cultural and economic changes in work, has been demanding new competency profiles. However, the hegemony of practices guided by behavioral and fragmented educational objectives reveals challenges to the amplification of the dialog between education and work.
The theoretical-methodological discussion according to which professional competence should guide health education depends on the construction of professional profiles grounded on models that must be coherent with what we intend to institute. The definition of profiles according to the holistic and dialogic framework represents an integrative approach in relation to the constituent elements of competence and to the different perspectives and values of the actors involved in this construction.
Education and certification models that use certifiable professional activities should, in consonance with the integrative framework of competence, employ a modeling that articulates action, capacities, context, and excellence criteria in the definition of entrustable activities. More than fifteen years after its introduction, the concept of EPA has been appropriated even by atomistic approaches to competence, which use isolated and fragmented capacities of professional practice, both in education and in education assessment.
In this sense, one of the greatest challenges for the integration of cognitive, psychomotor and attitudinal capacities lies in the tendency to fragment educational objectives. Such fragmentation, which results in an isolated approach to competence elements, is associated with decontextualization of knowledge and uncritical reproduction of professional practice.
The dialogic approach is a theoretical-methodological proposal that seeks to face this challenge by means of the articulation between the constituent elements of competence and through the dialog between complementary or apparently contradictory views and values in the definition of professional profiles. It reflects the complexity of professional practice, which mutually transforms work and education and produces reflexes on education and professional certification processes.