Validation of a competency matrix for nurses to address social inequalities

Kênia Lara da Silva¹, Elen Cristina Gandra², Rafaela Siqueira Costa Schreck³, Bruna Dias França⁴, João André Tavares Álvares da Silva⁵

^1,2,3,4,5Federal University of Minas Gerais. Belo Horizonte (MG), Brazil.

Introduction

Social inequalities pose a significant challenge to ensuring social justice and equity in health. Particularly in the current complex context, marked by new demands and needs, it is essential to analyze the inequality manifestations as a condition for accessing basic rights.

In this scenario, the role of health professionals—especially nurses, who represent the largest workforce in health systems—is critical in addressing social inequalities. Such inequalities are recognized as both material and existential disparities among individuals and population groups.¹ Without a fundamental shift in social practices, those inequalities will persist and continue to directly impact the health care sector. Considering the aforementioned points, it is necessary to implement strategies aimed at reducing them.²

The crisis brought on by the coronavirus disease 2019 (COVID-19) pandemic significantly to the rise in inequalities, as it drastically disrupted Brazil’s socioeconomic context throughout 2020.³ The economic downturn and escalating unemployment had an immediate impact on poverty rates. According to the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística, IBGE), the proportion of people living in extreme poverty rose to 9%, underscoring the deepening of social disparities in the country.⁴

The reduction of inequalities is a global concern and forms one of the Sustainable Development Goals (SDGs) in the United Nations' 2030 Agenda. Within this context, the pursuit of innovative, creative, and effective alternatives to reduce inequalities becomes an urgent challenge for society.⁵

Nursing plays a crucial role in addressing inequalities through actions related to education, care, administration, research, and political engagement within the services in which nurses are embedded.⁶ Accordingly, the development of competencies that enable nurses to act upon the conditions that produce inequality is of paramount importance. Caring for the health of vulnerable individuals requires professionals to adopt a transformative approach. In this sense, a critical and reflective educational foundation is both a revolutionary and necessary strategy to confront social inequalities.⁷

Professional education constitutes a distinct field that contributes to individual development, building upon acquired knowledge and lived experiences.⁸ Furthermore, it may be considered a transformative strategy that enables professionals to mobilize their personal resources synergistically in practical action.⁹ Competency, in this context, is understood as the ability to effectively intervene in various spheres of life, drawing simultaneously and interdependently upon attitudinal, procedural, and conceptual components.¹⁰

Despite the thematic relevance, there is a noticeable gap in the systematization of specific competencies aimed at addressing social inequalities within nursing education. Such competencies have been developed in undergraduate nursing programs in Brazil without being specifically tailored to the professional role of nurses.¹¹ Under these circumstances, the development of a set or matrix of competencies to guide nursing practice in confronting social inequalities represents an important demand within the field of nursing education.

This need becomes even more crucial when considering that over 60% of nurses in Brazil work within the Unified Health System (Sistema Único de Saúde, SUS),¹² where barriers to health care access persist due to disparities in infrastructure, human resources, access to medications, and the availability and coverage of health programs.¹³ Thus, in addition to investments in SUS and other public policies, strategies and actions are essential to reduce inequalities and to promote equitable health care.¹⁴

Accordingly, this study is justified by the need to develop a competency matrix for nurses to address social inequalities, intended to guide professional training and promote the development of competencies that enable effective responses to such challenges. It is important to emphasize the responsibility of nursing professionals as strategic agents for transforming conditions of inequality, given that the guiding principles of the profession include the promotion of health equity and social justice.¹⁵ Moreover, nurses address social inequalities in a transversal manner, across care delivery, education, management, and research, through actions that expand access to services, strengthen public policies, and contribute to a critical, reflective, and socially committed professional education.¹¹

The objective of this study was to develop and validate a competency matrix for nurses to address social inequalities within nursing education.

 Method

This is a methodological study with a quantitative approach, based on Pasquali’s psychometric framework,¹⁶ for the development and content validation of a competency matrix.

To validate this matrix, we employed theoretical, empirical, and analytical procedures.^17-18 The development and content validation of the competency matrix took place between June 2021 and March 2022, following theoretical stages (conceptual framework, definition of objectives and target audience, construction of matrix items, and selection and organization of items); empirical stages (structuring of the validation instrument, application of the Delphi technique, and content validation); and analytical stages (empirical analysis of the items and final validation of the instrument).^16-17

In the theoretical stage, we presented results from the literature review to identify scientific evidence on the contents and concepts related to competencies for addressing social inequalities. The initial stage of matrix construction was guided by the theoretical framework and the concept of competency defined by Zabala and Arnau.¹⁰ Subsequently, a scoping review was conducted to synthesize the scientific evidence regarding the competencies required of nurses to act upon social inequalities. Based on this evidence, the structural aspects of the matrix were defined, along with its target audience—namely, nurses and nursing students. The reduction of inequalities is recognized as a global concern, and finding solutions in this field requires an appropriate set of competencies among health professionals, including nurses.

In the empirical stage, content validation was conducted by experts. In this phase, the Delphi technique was applied, comprising the following steps: development of the Delphi questionnaire, selection of judges based on their expertise, and consensus building through multiple response rounds.

The Delphi questionnaire was administered online via the SurveyMonkey platform and was structured into four sections: (1) Presentation of the questionnaire, including participant information and instructions; (2) Informed Consent Form (ICF); (3) sociodemographic data; and (4) competency matrix for addressing social inequalities, along with the evaluation criteria for the judges. Data collected through SurveyMonkey were exported and analyzed using Microsoft Excel.

According to Pasquali,¹⁶ the competency matrix was evaluated based on the following criteria: clarity, simplicity, relevance, and precision. These criteria were presented on a Likert scale ranging from one to four. If a judge assigned a rating of one or two, a justification was required. Accordingly, the questionnaire was structured to allow each participant to provide feedback on each competency and suggest new competencies based on their experience.

To identify the judges, a search was conducted on October 25^th, 2021, using the “search by subject” field on the Lattes Platform of the Brazilian National Council for Scientific and Technological Development (CNPq), with the descriptors “social inequalities, competencies, education, nursing.” Experts were selected through judgment sampling, based on the following inclusion and scoring criteria: holding a degree in nursing (basic requirement); having a doctoral degree (two points); having written a thesis or dissertation on competencies and inequalities; supervising undergraduate and graduate research (two points); participating in research groups with publications on competencies and social inequalities within the last five years (two points); teaching in undergraduate and graduate nursing programs (two points); and developing outreach activities on the topic of inequality (two points). Experts scoring at least three points were included.

As a result of the search, 305 potential curricula were identified for inclusion in the expert panel. Of these, 281 were excluded for not meeting the selection criteria, and 19 experts did not respond to the study invitation. The final sample consisted of five expert judges.

The limited number of professionals who met the selection criteria highlights the scarcity of specialists with specific experience in the field of social inequalities. Furthermore, the low response rate to the initial invitation and participant withdrawal are common challenges in this process.¹⁸

Comprised by five experts (n=5), the final sample of judges aligns with the literature, which does not establish a consensus on the ideal number of experts to be included in studies of this nature. A review study analyzing publications that used this method indicated that the number of experts may vary depending on the study’s objectives, the complexity of the instrument being evaluated, and the availability of qualified professionals. Reported samples range from as few as three to well over one hundred participants.¹⁸ Nonetheless, it is acknowledged that this limited number may represent a constraint of the study, particularly with regard to the diversity of perspectives, and should be considered in future research.

Once the list of selected expert judges had been finalized, the content validation process began. An invitation email was sent to the judges, including an introduction to the research and its objectives, a copy of the proposed competency matrix to be validated, and a link to the Delphi questionnaire. After participants provided online consent, the study proceeded in accordance with ethical procedures for online research environments.

The estimated number of Delphi rounds was three. The goal of these rounds was to reach an understanding of the experts’ perspectives regarding the intended outcomes.¹⁸ Throughout the rounds, the competency matrix was submitted for expert review, during which participants provided their opinions regarding agreement or disagreement with each evaluated item.

During these rounds, divergent responses among participants and their underlying reasons were explored. After each round, results were analyzed using the Content Validity Index (CVI), and the need for incorporating new items was assessed before resubmitting the instrument for further evaluation by the judges. A CVI greater than 0.80 was adopted as the threshold.^19-20 To calculate the index, we used the formula: the number of items rated as three or four by the judges divided by the total number of answers (CVI=Number of ratings of three or four/Total number of answers). In this study, two rounds were sufficient, in accordance with the methodological criteria described. The first round included responses from five experts; in the second round, responses were obtained from four.

Following questionnaire completion, the open-ended responses were analyzed and interpreted. This analysis was carried out in both rounds to ensure that all of the judges’ considerations were addressed.

Based on the results, the authors proposed the final version of the Competency Matrix for Nurses to Address Social Inequalities.

The study followed the guidelines set forth in resolutions No. 466/2012 and No. 510/2016, and was approved by a Research Ethics Committee under Ethical Review Submission Certificate (Certificado de Apresentação de Apreciação Ética, CAAE) No. 44851015.4.0000.5149. The participants were assigned identification codes to ensure confidentiality and anonymity.

 Results

Five experts participated in the first validation round, three of whom were female. All participants held degrees in nursing and a doctoral degree: three held doctorates in nursing, one in education, and one in psychology. It is worth noting that three of the experts were professors at public universities and two at private universities in Brazil, and all had scientific publications related to the study’s topic of interest.

In the second round of validation, four of the five experts participated, two of whom were female. Among them, three held doctorates in nursing and one in psychology. One expert did not return the matrix evaluation within the established deadline and, as a result, did not take part in the second round.

The Competency Matrix

During the construction phase of the matrix elements and items, four competency domains were defined, organized into increasing levels of complexity (identification, analysis, actions, and transformation), comprising 15 general competencies and their corresponding actions or specific competencies. The model was structured to present each domain along with its definition, followed by its respective general competencies and related actions. These actions—also referred to as specific competencies—represent the most concrete dimension, from which success indicators can be extracted to assess the achievement of each competency. The matrix was schematically organized to include four domains and the 15 defined competencies.

The first competency domain was identification, which involved the ability to recognize and understand social inequalities, identifying situations, facts, contexts, or conditions that generated or reflected inequality. This domain included three competencies and their respective actions, with the expectation that students would be capable of recognizing, discerning, and understanding social inequalities.

The second domain was analysis, reflecting the ability to examine, investigate, measure, or critically reflect on situations, facts, contexts, or conditions of inequality experienced by individuals, groups, or populations. It also included the capacity to debate and problematize the circumstances, causes, and determining factors of such inequalities. This domain also comprised three competencies, with the expectation that students would be prepared to examine, reflect on, and problematize social inequalities.

The third domain was actions, comprising five competencies. It was expected that students would be prepared to demonstrate the capacity for emancipatory action in response to situations, facts, contexts, or conditions of inequality experienced by individuals, groups, or populations. This domain presupposed leadership, engagement, and decision-making in the development of actions, strategies, and policies aimed at addressing social inequalities.

The fourth and final domain was social transformation, which included four competencies. Students were expected to be prepared to transform situations, facts, contexts, or conditions of inequality by innovating processes, negotiating conflicts, reinterpreting actions, and ultimately impacting the ways of life of individuals, groups, and populations. This domain involved forming judgments and committing to action, mobilizing values, confronting dilemmas, and deciding on what was deemed the best course of action. It encompassed actions and strategies for social change.

Content Validity of the Competency Matrix

After reaching consensus with the expert panel, the four domains remained unchanged; however, the competencies themselves were revised and adapted (Chart 1).

Chart 1 - Items modified for the second round, based on expert suggestions, in the Competency Matrix for Nurses to Address Social Inequalities. Belo Horizonte (MG), Brasil, 2022.

Before	After
Domain 1: Identification
D1C1. Recognize social inequalities -        Identify situations of inequality and injustice involving different social groups -        Identify inequities related to ethnic and cultural diversity -        Detect indicators or parameters of vulnerability	D1C1. Perceive social inequalities -        Perceive situations of inequality and injustice involving different social groups -        Identify inequities resulting from discrimination/prejudice -        Investigate/identify indicators or parameters of vulnerability
D1C2. Discriminate social inequalitie -        Characterize available resources and support networks within the territory for addressing inequalities -        Distinguish types of violence -        Differentiate the needs and vulnerabilities of individuals and social groups	D1C2. Classify social inequalities -        Discern types of violence generated by inequalities -        Differentiate the needs and vulnerabilities of different individuals and social groups
Domain 2: Analysis
D2C3. Problematize facts, contexts, or conditions of social inequalities -        Question ethnic and cultural diversity in the workforce -        Problematize forms of violence -        Challenge policies addressing inequalities -        Confront situations of injustice between social groups	D2C3. Problematize facts, contexts, or conditions of social inequalities -        Question ethnic and cultural diversity in the workforce -        Problematize forms of violence -        Understand public policies for addressing social inequalities within the context of societal power relations -        Confront situations of injustice between social groups
Domain 4: Transformation
D4C1. Resolve situations of social inequality -        Reduce the causes of violence -        Expand resources and support networks for vulnerable groups in addressing inequalities -        Reduce or eradicate poverty	D4C1. Resolve situations of social inequality -        Reduce the causes of violence -        -           Expand resources and support networks for vulnerable groups in addressing inequalities -        Engage in movements or groups aimed at poverty eradication

CVI: Content Validity Index; D: Domain; C: Competency.

In the reliability assessment, the CVI demonstrated satisfactory overall internal consistency in 11 out of the 15 competencies proposed within the matrix domains. However, adaptations were required for competencies 1 and 2 in domain 1, competency 3 in domain 2, and competency 1 in domain 4. The experts’ suggestions regarding the matrix items referred primarily to textual adjustments.

The experts carried out the content validation process of the instrument’s items according to the criteria of clarity, simplicity, relevance, and precision (Chart 2). Items with agreement percentages below 80% were revised accordingly.

Chart 2 - Distribution of items in the Competency Matrix for Nurses to Address Social Inequalities, according to the percentage of agreement among experts. Belo Horizonte (MG), Brasil, 2022.

Items	CVI
	CL	SP	PT	PC	Overall
Domain 1: Identification
D1C1 - Perceive social inequalities	1.00	1.00	1.00	1.00	1.00
D1C2 - Classify social inequalities	0.75	1.00	1.00	1.00	0.94
D1C3 - Understand social inequalities	0.83	0.83	1.00	1.00	0.92
Domain 2: Analysis
D2C1 - Examine social inequalities	0.83	0.83	1.00	0.83	0.88
D2C2 - Review situations or conditions of social inequality	0.83	1.00	1.00	0.83	0.92
D2C3 - Problematize facts, contexts, or conditions	0.75	1.00	1.00	1.00	0.94
Domain 3: Actions
D3C1 - Develop actions to address inequalities	1.00	0.80	1.00	0.80	0.90
D3C2 - Provide care to individuals, groups, or populations in situations of inequality	1.00	0.80	0.80	0.80	0.85
D3C3 - Collaborate in efforts to address social inequalities	1.00	1.00	1.00	1.00	1.00
D3C4 - Mobilize individuals, groups, or communities in addressing inequalities	0.80	0.80	0.80	0.80	0.80
D3C5 - Advocate for actions to address social inequalities and promote social justice	1.00	0.80	1.00	1.00	0.95
Domain 4: Transformation
D4C1 - Resolve situations of social inequality	0.75	0.75	1.00	1.00	0.88
D4C2 - Improve conditions of inequality	0.80	0.80	0.80	0.80	0.80
D4C3 - Transform contexts of inequality	1.00	1.00	1.00	1.00	1.00
D4C4 - Reinterpret facts, concepts, or conditions related to social inequalities	1.00	0.80	1.00	1.00	0.95

CL: Clarity; SP: Simplicity; PT: Pertinence; PC: Precision; D: Domain; C: Competency.

The final version of the competency matrix for nurses to address social inequalities, validated after the second round of the Delphi technique, is presented below (Figure 1).

Figure 1 - Competency matrix for nurses to address social inequalities in nursing education, after validation. Belo Horizonte (MG), Brasil, 2022.

Discussion

Reducing inequalities is a global concern and constitutes one of the Sustainable Development Goals (SDGs) of the United Nations' 2030 Agenda. The search for innovative, creative, and effective alternatives to confront these inequalities remains a challenge for diverse societies.⁵

In this context, the development of the competency matrix for nurses to address social inequalities represents a pedagogical advancement in the field of health professional education, by proposing a theoretical and practical tool capable of guiding professional training on this issue. It serves as an educational resource that contributes to the development of specific competencies to be mobilized in nursing practice, in response to the profession’s social and ethical demands, and with potential applicability across other health disciplines. The matrix enables the construction of knowledge regarding the competencies needed to address social inequalities. Beyond its scientific relevance, it enhances both nursing knowledge and care. The specificity of competency development for professional action in the context of social inequalities, combined with the scarcity of studies on the subject, underscores the need for evaluation processes in this area, supported by theoretical and methodological rigor and clear criteria for validity and reliability.

The design and validation of an educational instrument aimed at guiding the development of nurses’ professional competencies to act on social inequalities—one of the greatest emergencies of the 21^st century²¹—directly contributes to nursing practice. Added to this context are educational challenges related to technological advancement, new forms of social interaction, and competitive dynamics in the job market.²²

Therefore, the validation of curricular matrices through instruments with specific content—such as a competency matrix—stands out as an innovative tool for nursing education. It serves to guide educators on the necessary actions for developing competencies related to addressing social inequalities. Among the essential characteristics of a well-designed instrument are objectivity and clarity,²³ which were considered across all items in this study’s matrix.

One of the main barriers in health education is the disconnect between theory and practice.²⁴ Often, educational programs fail to adequately address the issue of social inequalities, and instead tend to replicate the very social structures that sustain them. This undermines the pursuit of equity and comprehensive care—both of which are fundamental principles of the Brazilian Unified Health System (SUS).²⁵ Therefore, studies that promote this curricular integration from the early stages of training are essential to overcoming this barrier.

According to these authors,²⁵ other challenges regarding the applicability of competency matrices must also be addressed. In the context of this study, particular challenges include: promoting collective and continuous faculty development; determining the appropriate stages of the course at which to assess competencies; identifying the most suitable assessment instruments for different domains and subdomains; and developing educational strategies that reflect the complexity of the competencies to be developed, as well as practical settings for their application and experimentation.

This study’s methodological rigor in constructing and validating the matrix is noteworthy, as it enables its replicability and adaptation across different contexts beyond nursing education. Furthermore, content validation—based on the criteria of clarity, simplicity, relevance, and precision—constitutes a fundamental step in consolidating the knowledge produced and ensuring the adequacy of the competencies represented in the construct. This contributes to the enhancement of professional training.

Accordingly, the matrix emerges as a tool that can serve as a reference for guiding educational parties—such as academic administrators, faculty, and students—involved in the teaching-learning processes in nursing education. However, it is recommended that the instrument be further applied among educators and the target audience in order to refine methodological choices, particularly regarding the matrix’s clarity and precision.

Given the broad impact of inequalities across multiple contexts, the matrix’s potential for interprofessional application is reinforced. It can be adapted to other health-related programs through new validation studies. Interprofessionalism emerges as a strategic response to the historically fragmented model of health education and practice. Health training, traditionally structured along disciplinary lines, tends to emphasize the specific competencies of each profession. This approach hinders the development of shared mental models, the construction of a collective identity, and the mutual recognition, appreciation, and respect among different professional fields.²⁴

In this regard, expanding the matrix’s application to faculty and students across various health programs may represent a meaningful step toward advancing interprofessional education. Such expansion can foster the integration of knowledge and practices, promote collaborative learning, and enhance teamwork—all of which are essential elements for building more comprehensive health education. The adoption of interprofessional approaches in the training process contributes to the development of collaborative competencies and to the strengthening of more resolute, patient-centered practices focused on the principles of comprehensive care and equity.²⁴

As a limitation of this study, it should be noted that the matrix was applied exclusively within the context of nursing education, which restricts the scope of the data obtained in relation to other health disciplines. However, this delimitation does not diminish the matrix’s potential, as it can be adapted and applied to other health-related programs, particularly given the relevance of social inequalities, which have a transversal impact across various fields of health care practice. This reinforces the matrix’s applicability in interprofessional contexts, provided that further validation studies are conducted to account for the specificities of each profession. Another limitation concerns the number of experts involved in the matrix validation. Nonetheless, there is no consensus in the literature regarding the ideal number of participants for such studies.¹⁸

The number of experts participating in this study reflects the current state of the field. Of the 19 professionals who met the inclusion criteria, only five agreed to participate in the validation process. This not only highlights the scarcity of specialists with direct experience in the field of social inequalities, but also the recurring challenges of securing engagement in studies of this nature. Low response rates to initial outreach and participant dropout throughout the process are commonly observed.¹⁸ To address this challenge in future research, it is recommended to strengthen collaborative networks among institutions and researchers in order to ensure greater mobilization and engagement of specialists with expertise in the field, thereby broadening the diversity of perspectives in the evaluation process. Furthermore, it is essential to encourage the involvement of new researchers in the field of social inequalities, given its increasing relevance and the urgent need to expand the scientific discourse surrounding this topic.

 Conclusion

Competency-based education is understood to require the development, in students and future health professionals, of the ability to mobilize knowledge, skills, and attitudes to address real-life situations—including dilemmas related to social inequities and various contexts of social vulnerability.

The globalized context of health practice, in which health problems transcend national boundaries, demands that nursing professionals, beyond technical competencies, receive a comprehensive education that respects the unique characteristics of each society. This perspective challenges the utilitarian view often associated with the concept of competency, which is frequently tied to market demands or treated as a model or standard to be followed. In this regard, the competencies developed in nurses are expected to contribute to the training of critical and reflective citizens in the contemporary world—professionals capable of challenging the paradigm that naturalizes social inequalities.

In this sense, the proposed competency matrix emerges as an innovative strategic tool with the potential to impact the quality of nursing education. By fostering the development of competencies aligned with the actual needs of the population and the principles of the SUS, the matrix is expected to contribute to the consolidation of more just, ethical, and effective professional practices in addressing social inequalities. In addition to its pedagogical value, the matrix may also inform public policies aimed at promoting curricular reform in health education, serving as a foundation for the development of educational guidelines that support the training of professionals with both technical excellence and social responsibility. By guiding the construction of learning pathways that are more attuned to social inequalities, this instrument becomes a key element in promoting equity in health care and, consequently, in strengthening the SUS.

Authors Contributions

Study concept: Kênia Lara da Silva. Data collection: Kênia Lara da Silva, Rafaela Siqueira Costa Schreck, Elen Cristina Gandra, Bruna Dias França, João André Tavares Álvares da Silva. Data analysis and interpretation: Kênia Lara da Silva, Elen Cristina Gandra, Rafaela Siqueira Costa Schreck, Bruna Dias França, João André Tavares Álvares da Silva. Writing the manuscript: Kênia Lara da Silva, Elen Cristina Gandra, Rafaela Siqueira Costa Schreck, Bruna Dias França, João André Tavares Álvares da Silva. Critical revision:  Kênia Lara da Silva, Elen Cristina Gandra, Rafaela Siqueira Costa Schreck, Bruna Dias França, João André Tavares Álvares da Silva. Approval of the final version: Kênia Lara da Silva.

 Conflict of interest

The authors declared that there is no conflict of interest.

Funding

Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq

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Corresponding Author

Name: Kenia Lara da Silva

E-mail: kenialara17@gmail.com

© The Author(s) 2025. This work is licensed under Creative Commons Attribution 4.0 International. License text for use: https://creativecommons.org/licenses/by/4.0/