Competencies in health promotion by nurses for adolescents

Objective: to describe the health promotion competency domains, performed by nurses, for adolescents, according to the Galway Consensus. Method: a qualitative study based on the Galway Consensus theoretical methodological framework. Fifteen nurses from northeastern Brazil participated. Data were collected between April and May 2017 through pre-structured interviews, submitted to the content analysis technique and analyzed according to the Galway Consensus dimensions. Results: the following competency areas were found: catalyzing changes, leadership, needs assessment, planning, implementation, and partnerships. These competencies were contemplated from embracement of adolescents at health unit, guidance, teamwork, educational activities and lectures, as well as active search. Conclusion: most health promotion domains were observed; however, it is still suggested that there are challenges to an effective performance of health promotion among adolescents because some competency domains in health promotion have not been evidenced. Adolescent; Nursing; Nursing Evaluation


INTRODUCTION
Health promotion is defined as a process of community training to work on health improvement (1) . However, it is significant to emphasize that initially primary care areas, health care for children and women were prioritized, and then, attention to adolescents was considered (2) .
Nowadays, adolescents have been a target for creating public policies that strengthen health promotion actions aimed at guaranteeing the Millennium Development Goals, aiming at health development for a productive adult life. In this regard, this age group is considered vulnerable, permeated by risk situations such as alcohol and tobacco use, insufficient physical activity, unprotected sexual intercourse and exposure to several forms of violence, which can harm health in the short or long term in terms of biopsychosocial and spiritual well-being aspects (3)(4) .
In this context, nursing stands out as a profession for health care promotion as well as for gathering and insertion of adolescents in health-promoting actions in order to reduce the vulnerabilities that adolescents are exposed to and contribute as an instrument of changes in health care practices. Although intense movement and actions aimed at promoting health are recognized, health services may not address adolescents' needs, since they are people with characteristics of risks, vulnerabilities and demand specific demands of care (5)(6)(7) .
It is recommended that the approach model is the one in which adolescents are protagonists as well as the focus of discussions on the reasons for the need for behavioral changes and the search for life quality (6) .
In this perspective, it is needed to search for references and care models that value care actions for specific competencies -with emphasis on the Galway Consensus, held in Ireland in June 2008aiming at identifying and developing workforce and competencies for health promotion. In this framework, eight competency domains necessary for effective health promotion are defined: catalyzing changes, leadership, needs assessment, planning, implementation, impact assessment, rights defense and partnerships (8)(9) .
Health competency is the ability to accomplish something, in a specific situation, which is related to learning, knowledge acquisition and reconstructing knowledge. Thus, to develop effective health promotion actions, acquiring competencies is a guide for developing professional ability (10)(11) .
The Galway Consensus gathers eight domains of health promotion competencies and is inherent to nurses' work, as it highlights the ability to operate resource management in order to improve their articulation with work and education, and thus optimize health care for the population (12) . Additionally, competencies are essential for health promotion foundation, giving it quality by combining knowledge and competencies in a specialized field of practice (13) .
Nurses' performance in primary health care needs to incorporate health promotion competencies in adolescent health care. In this context, considering the problem on the referred theme and actions to promote adolescent health, we aimed to answer the following guiding question: what competency domains in health promotion -included in the actions performed -are developed by nurses for adolescents?
This study is relevant because it allows reflecting on nurses' care practices with adolescents as well as discussing about the inseparable health promotion to nurses' work, guided by professional competencies, considering the complexity of public health policies.

OBJECTIVE
This study aimed to describe the health promotion competency domains, performed by nurses, for adolescents, according to the Galway Consensus.

Ethical aspects
The guidelines and regulatory rules for research with human beings were observed. All participants were informed about the purpose of the study, signed the Informed Consent Form (ICF) and had their anonymity assured. There were minimal risks to participants, such as embarrassment, but it was reduced when discussing the importance of this study for them. This study was approved by the Research Ethics Committee (REC) of Universidade Regional do Cariri and CAAE (Certificado de Apresentação para Apreciação Ética -Certificate of Presentation for Ethical Consideration).

Theoretical-methodological framework
To develop this study, the Galway Consensus theoretical-methodological framework was adopted, which includes eight areas of competency for building global work capacity in health promotion.
The first domain refers to catalyzing changes that correspond to needs for change and individuals' and communities' empowerment to improve their health. The leadership domain corresponds to professionals' strategic orientation for participation and development of healthy public policies in the management of resources for health promotion. The needs assessment domain involves the need to assess the biopsychosocial context of individuals and communities and factors that compromise health (8,13) .
The fourth domain refers to a planning that corresponds to proposing viable strategies in response to assessment of individuals' and communities' needs. The implementation domain comprises an effective and active, culturally sensitive and ethical implementation of strategies for health improvement. The impact assessment domain corresponds to determining the scope and effectiveness of the results of interventions planned by professionals. The advocacy domain involves professionals' work to advocate on behalf of individuals and their community to improve their health and well-being. The partner domain corresponds to collaboration between courses, sectors and partners for promoting health for individuals and communities (8,12) .

Study design
This is a descriptive and qualitative study.

Study setting
This study was conducted with Primary Health Care nurses from a city in northeastern Brazil. Nurses working at Primary of Competencies in health promotion by nurses for adolescents Carmo TRG, Santos RL, Magalhães BC, Silva RA, Dantas MB, Silva VM.
Health Care services in the urban area of a city were considered eligible because there were most of professionals.
Eighteen nurses from these health services were eligible. Nurses linked to Primary Health Care services, with at least one year of work experience in that place were included. Nurses who were absent from health services, due to any reason, during the data collection period were excluded. During the data collection period, two were on vacation and one professional, even after scheduling data collection, declared that he was unable to participate. Thus, 15 nurses were interviewed and data collection ended after reaching saturation.

Data source
This study was developed through identification of possible interviewees for the study and contact with nurses and scheduling interviews. Nurses participated of the study after the completion of all described steps. Participants were identified by numbers of ascending order of data treatment and this made it possible to preserve anonymity (nurse 1, nurse 2... nurse 15).

Data collection
Data collection was held through interviews, which took place after scheduling, from April to May 2017, according to participants' availability, in a reserved space in a health unit, performed individually. Each interview lasted around 32 minutes. The statements supported the construction of analytical categories, characterized by health promotion competency domains. The semi-structured interview script was prepared based on the following question: what actions were taken with adolescents in order to guarantee health promotion in this circumscribed unit?

Data analysis
Interlocution ended after theoretical exhaustion, when the 15 nurses answered the questions asked, so that the findings became repetitive. Thus, this number made it possible to approach the object and identify common themes according to Galway Consensus, which allowed the focus of the study to be reached. All statements were identified by "Nurse", to identify the interviewees, in order to maintain anonymity, following the number indicating the order of data collection (1, 2, ..., 15).
Then, the findings were submitted to Bardin's content analysis method, which describes the stages of analysis organization such as pre-analysis, material exploration and treatment of results. After full transcription of all interviews, the text was skimmed, which allowed the corpus definition to be analyzed. The analytical categories were defined, a priori, according to the Health Promotion Competencies framework to Galway Consensus and other studies relevant to the theme.

RESULTS
Participants were predominantly women (13) in relation to the quantity of men (02). The age of nurses ranged between 34 and 40 years old (12 nurses) and from 44 to 51 years old (03 nurses).
Concerning time passed after graduation, they were between 11 and 25 years. As for job tenure, there was a variation between 2 and 17 years.
It is presented the categories, evidenced by Galway Consensus domains, performed by nurses with adolescents, aiming health promotion. From nurses' statements, it was noticed that six domains, from Galway Consensus, were evidenced: Catalyzing changes, Leadership, Needs assessment, Planning, Implementation, and Partnerships.

Catalyzing change
This domain was evidenced through actions to encourage adolescent participation in orientations about body knowledge and disease prevention. [

Leadership
In this study, the leadership domain stands out for nurses' initiative to conduct assistance focused on the adolescents' real needs and health priorities management for this public.
[...] whenever an adolescent arrives, I make it a priority. Because we know that there are many problems inherent to this age group, and that they often seek out colleagues, who do not pass on correct information... so we try to welcome them, with a certain priority, as far as possible. (Nurse 2) Mobilization of other professionals stands out in order to contribute and multidisciplinary actions, which are encouraged by nurses. The characterization and identification of social problems contribute to recognizing adolescents' health needs, inferring with the importance of strategies aimed at their reduction and health promotion. [ The difficulty in getting support from other agencies goes counterpoint to the needs assessment held by professionals, hindering the intersectoral approach between health and education, being essential for health promotion.

Implementation
The implementation domain was evidenced through health care for pregnant adolescents, educational lectures and innovative strategies for the audience in general.

Partnership
Partnership is noticed mainly by the mutual cooperation between nurses and school as well as articulation and assistance from the Family Health Support Center (FHSC). [ The intersectoral nature of actions contributes to adolescents' health in which they are encouraged to know and seek other support services, contributing not only to prevention, but also to comprehensive care. [...]

DISCUSSION
The emerging necessity to develop competent in health promotion by nurses is fundamental for defining the essential competencies in this field, which can be important for building a new care model focused on adolescents.
The Catalyze Change competency empowers individuals and the community to improve their health, encouraging change production (8)(9) . From the data found, this competence is contemplated by nurses when they portray the search for improvement in welcoming adolescents and eliminating barriers between this public and the Basic Health Unit through guidance on diseases and the importance of knowing the body and disease prevention, empowering adolescents taking care of themselves at this stage to eliminate possible health risks in adulthood.
It was also emphasized the importance of inserting themes that go through the changes that occurred in adolescence, something recurrent in the health education of this public. The nurses' statements in this study emphasizes neglected diseases such as leprosy, which are also emerging. These characteristics provide greater autonomy and self-care in adult life.
It is possible to observe the primary health care process challenge concerning implementing organized, effective and specific actions for adolescents; most of time, it seems that there are no actions focused on the specificities of adolescence. Besides that, the inexistence of innovative strategies and captivating approaches, due to the deficit of continuing education of professionals, leads to resistance from this public (14)(15) .
According to the Galway Consensus, the leadership competency deals with directing strategies that support healthy public policy development, resource mobilization and management for health promotion and capacity building (8)(9) . The leadership competency indicates the need for greater actions aimed at this audience, considering the difficulty of adolescents to seek primary health care services.
Determining the scope, effectiveness and impact of health promotion policies and programs includes an appropriate organization of evaluation and research methods to underpin program improvement, sustainability, and dissemination (16) . In this research, nurses sought for optimizing the entry of adolescents into the health service and perform strategies for specific actions, such as vaccination. This action is important for disease prevention and link formation between professionals and adolescents.
Needs assessment is related to analysis of social, cultural and environmental conditioning as well as of organizational determinants that favor health promotion or commitment (8)(9) . The public at which this study is focused reported the need for strategies directed to sexuality and drug use prevention among adolescents. These findings are consistent with a study that highlighted nurses, as trainers and educators, have the basic function of assessing and knowing the environment in which these adolescents are inserted, in order to identify their vulnerabilities and needs in the biopsychosocial context (17) . In this study, health promotion aimed at leprosy assessment and knowledge stands out. Such point of view differed from other perspectives and may be related to the reality of the region studied.
Planning is interrelated to needs assessment, and aims at determining plausible and achievable goals as well as strategies based on theories and scientific and practical evidence (8)(9) . This research exposes the articulation of Community Health Workers in the search for adolescents, organization of educational actions regarding material and personal resources, and active search of adolescents as a strategy to attract and insert them in the health unit.
Establishing a bond with adolescents is a perceived barrier in health services. In this field, it is emphasized using theoretical knowledge to develop nursing actions aiming at promoting health (18) .
Published studies (19)(20) bring the qualification of primary health care through activities with adolescents in groups, educational and health promotion actions, whose positive results are related to the factors that aroused adolescents' interests, such as methods used that favored dialogue, exchange of experiences and reflection on their own practices, relationships with groups of friends/families. Developing such actions is justified by the low frequency of adolescents in health services, which requires assertive activities involving them. Moreover, the involvement of adolescents facilitates identifying facilitating and inhibiting factors to promote essential health strategies (14,21) .
The implementation competency is characterized by the effective and efficient realization of ethical and culturally accepted strategies in order to ensure possible improvements to health including planned actions, which involves human and material resources (6)(7)22) .
In this competency, it is observed the implementation of broad actions, directed to the most common problems faced by this public, such as Sexually Transmitted Infections, drugs, alcohol and sexuality. The breadth of these themes is fundamental since the vulnerabilities found by this population and the need for diverse actions in order to enable prevention of diseases in this period of life that may influence adult life.
It is perceived that implementation, planning and partnerships competencies are interconnected, emphasizing the presence of family and school as essential links to health promotion. This connection is also noticed in other studies, basing its importance to health (18) . Intersectoriality and partnerships with other institutions are important for the effectiveness and success of developed actions. The school has an essential role in this competency as well as sending adolescents to another professional in order to promote a complete care.
There are other studies which corroborate by stating the correlation of catalyzing change, leadership and partnerships domains with health promotion implementation (12) . It is important to stress the need for planned and systematized educational interventions by nursing, with emphasis on educational technologies for health promotion, considering their attractiveness for adolescents and potentiator of their autonomy (23)(24) .
In order to make these competencies effective, nurses must act as learning and empowerment facilitators, transforming themselves into health promotion workers. When followed, the competency domains play a fundamental role in changing the medical-hegemonic and disease-centered model. Thus, it is highlighted the relevance for nursing as a profession inseparable from health promotion, 7 of Competencies in health promotion by nurses for adolescents Carmo TRG, Santos RL, Magalhães BC, Silva RA, Dantas MB, Silva VM. following these competencies and acting under a new perspective, centered on adolescents as a whole, considering their aspirations for a better interaction between nurse and adolescent (25) .
The partnerships competency is related to cooperation between courses, sectors and partners in order to improve impact and sustainability (6)(7) . Health promotion actions, performed in partnership with other health professionals and other sectors of society, encourage the leadership of community members, which allows the dissemination of self-care for health and positively impacting the lives of adolescents and health services (26) . Despite the partnerships reported by nurses in this study, it is still observed that there may be difficulties regarding low demand for health services, by adolescents, and little attention to care actions.
The school acts as an important partner in promoting health for adolescents. Thus, partnerships between health and education should be encouraged as they facilitate assistance to adolescents aiming at preventing and improving their health (27) .
Nurses' partnership with Community Health Workers encourages the participation of adolescents in health services. This leader is a mediator between the health team and the community. Community Health Workers, through the adolescents' active search for services, contribute to promoting adolescents' health. Moreover, it can identify health problems that need intervention. Thus, it strengthens and encourages the search for health care (28) .
Health impact assessment and advocacy domains have not been raised in the interviewees' statements. However, it was found that the actions developed by nurses sought to promote the health of this population. In this context, they allowed health promotion optimization with adolescents, emphasizing the adequacy to the reality of health actions for the population studied.

Limitations of the study
This study is limited by the fact that part of inferences come from a particular context, and probably not possible to be generalized, due to the influence of cultural, economic and political factors inherent to the region in which this study is concentrated. Semi-structured script use was another limitation of the study. To this end, nurses were offered the possibility of adding, during the interview, other perceptions in relation to their work with adolescents. Therefore, other investigations are necessary for the generalization of the findings in similar realities.

Contributions to nursing, health, and public policies
This research contributes to nursing and has practical implications concerning studies on nurses professional competencies as they are seen as an inseparable aspect of a nurse's job, in his or her professional practice and in the development of public policies.

FINAL CONSIDERATIONS
The nurses' statements portrayed the following areas of health promotion competency in the Galway Consensus: catalyzing change, leadership, needs assessment, planning, implementation and partnerships.
Among the health promotion competencies areas of the Galway Consensus, two have not been highlighted: Health Impact Assessment and Advocacy. It suggests that there is a need for working them to the effective professional performance of nurses. Thus, such aspects may impact health promotion of adolescents. The evaluation and feedback of planned intervention actions and the search for adolescents' rights to public health policies is considered relevant.
It is realized the importance of the applicability of Galway Consensus competencies, considering the benefits offered to individuals and community, contributing to a full and healthy experience of adolescence, enhancing adult life.
In this regard, it is suggested that promoting adolescent's health, based on these competencies, should be enhanced and motivated, through continuing education of nurses and necessary subsidies for effective actions to promote health.