A training course on bioethics for family health strategy professionals in Santo André, SP

Abstracts

Relato de experiência da capacitação em bioética para enfermeiros e médicos da Estratégia Saúde da Família, Santo André, SP. Trata-se de trabalho calcado na problematização e bioética deliberativa, que objetivou apresentar o procedimento da deliberação para subsidiar o manejo de problemas éticos. Trabalharam-se os conteúdos transversalmente em cinco sequências de atividades, em dois momentos de concentração, intercalados por um de dispersão. Na primeira concentração, desenvolveram-se conceitos chaves e conteúdos da bioética deliberativa. Na segunda, houve sessões de deliberação para situações de conflito moral, selecionadas e preparadas durante a dispersão. Os participantes avaliaram a deliberação como um instrumental adequado para lidar com as questões éticas que vivem. A problematização mostrou-se efetiva como estratégia educativa na formação contínua em bioética deliberativa.

Bioética; Capacitação em Serviço; Pessoal de saúde; Atenção Primária à Saúde

EXPERIENCE REPORT

A training course on bioethics for Family Health Strategy professionals in Santo André, SP

Capacitación en bioética para profesionales de la Salud de la Familia del municipio de Santo André-SP

Elma Lourdes Campos Pavone Zoboli^I; Fátima Aparecida Cotrim Soares^II

^IRegistered Nurse. Post doctorate in Bioethics. Associate Professor of the Collective Health Nursing Department of the University of São Paulo School of Nursing. São Paulo, SP, Brazil. [e-mail]

^IIMSc student of the Post-graduate Nursing Program of the University of São Paulo School of Nursing. Registered Nurse of the Santo André Municipal Council. Santo André, SP, Brazil. [e-mail]

Correspondence

ABSTRACT

This case report presents the experience of a training course on bioethics for nurses and physicians of the Family Health Strategy in Santo André, SP. This study is based on problem-based learning and deliberative bioethics, and aimed at presenting the deliberation procedure as a means of handling ethical issues. Contents were addressed in a cross-section manner through five sequential activity sessions at two different moments of concentration with one dispersion interval. In the first moment of concentration, key concepts and deliberative bioethics contents were developed. The second involved deliberation sessions on moral conflicts, which were selected and prepared during the dispersion interval. Participants evaluated the deliberation as an appropriate instrument to deal with the ethical issues they are faced with. Problem-based learning was an effective educational strategy for continuing education in deliberative bioethics.

Descriptors: Bioethics; Inservice Training; Health personnel; Primary Health Care

RESUMEN

Relato de experiencia sobre la capacitación en bioética para enfermeros y médicos de la Estrategia Salud de la Familia, Santo André-SP. Enfocada en la problematización y bioética deliberativa, objetivó presentar el procedimiento de deliberación para coadyuvar el manejo de problemas éticos. Se trabajaron transversalmente los contenidos en cinco secuencias de actividades, en dos momentos de concentración, intercalados por uno de dispersión. En la primera concentración, se desarrollaron conceptos llave y contenidos de la bioética deliberativa. En la segunda, hubo sesiones de deliberación para situaciones de conflictos morales seleccionados y preparados durante la dispersión. Los participantes evaluaron la deliberación como un instrumental adecuado para lidiar con las cuestiones éticas que viven. La problematización se mostró efectiva como estrategia educativa en la capacitación permanente en bioética deliberativa.

Descriptores: Bioética; Capacitación en Servicio; Personal de salud; Atención Primaria de Salud

INTRODUCTION

Healthcare professions are distinguished by their ethical responsibility in dealing with the life and death thresholds of people and with their health, which can be simultaneously understood as a possession, a right and a value. However, faced with the current ethical problems that have arisen from advances in biotechnology, from changes and crises in the healthcare systems and from the recognition of the moral plurality of the users and workers, the codes of professional ethics have been used insufficiently. Thus, it is necessary to incorporate the continuous training of professionals for a new approach to ethics that fosters the acquisition of deliberative habits and considers the moral pluralism, the possibilities of the biotechnology and the transformations in the health and care. In the clinic, self-management is imposed; the paternalistic beneficence of the professionals to the autonomy of the users of the healthcare services. In Primary Health Care, the users are, however, more autonomous and the decision to treat them or not will largely depend on the relationships of bond and feeling, i.e. the ethics of the relationships. By including systematic training in knowledge, skills and attitudes, in a problematical rather than manipulative or indoctrinating way, promoting ethical competence, training in bioethics can provide professionals with a new way of critically approaching ethics in healthcare. Beyond being familiar with ethics, philosophy, legislation and deontological codes, the professional must be competent to deliberate, responsibly and prudently. This requires ethical competence⁽¹⁾.

Competence is the ability to act effectively in different professional situations, based on knowledge, but not limited to this. It is the ability to use, integrate or mobilize the knowledge and skills, aiming to solve everyday problems. Competence is not restricted to the technical context. The aim of awakening the critical and reflective capacity of professionals, includes the ethical and political areas⁽²⁾. The competent professional is able to judge, evaluate and consider problematic situations to find alternative solutions and decisions, also in the context of professional ethics. Ethical competence requires: knowledge of the ethical theories (to know); the ability to identify and resolve conflicts (to know how to do) and the true incorporation of ethical values and principles into the professional attitude toward the user and the team colleagues (to be/to coexist)⁽¹⁾. Studies with primary healthcare professionals in Madrid and São Paulo revealed the need for continuous training in bioethics^(3-4). The Madrid study highlighted the lack of training in bioethics and the need for more investment in this area to train primary healthcare professionals for the management and resolution of ethical conflicts⁽³⁾. The educational process in bioethics aims for the development of practical skills and has the goal of developing skills to analyze and resolve ethical conflicts autonomously and prudently, after a deliberative process⁽⁵⁾. Although it is recognized that the development of skills depends on knowledge, this is not very useful for the improvement of the practices and relationships in health, where the professionals know the history and foundation of bioethics perfectly, or even talk with ease about the ethical theories or the moral development phenomena, however are unable to identify and apply values and principles in the management of cases of conflict. Therefore, practical skills must take precedence over knowledge. However, both are merely means and instruments for the main purpose of the formative process in bioethics: to problematize the attitudinal aspects in order to transform the practice towards ethical excellence⁽⁵⁾. Therefore, the greatest challenge in teaching bioethics concerns attitudes, because they relate to the autonomous choices of each regarding the type of professional they aspire to be⁽⁶⁾.

The objectives of the training were: to provide knowledge of bioethics that enables the healthcare professionals to systematically analyze and critique the ethical aspects of their primary healthcare practice, considering the peculiarities of this context of the assistance; to support the process of decision making in the face of ethical problems in primary healthcare in order for the professionals to be able to debate with accuracy and consistency regarding their choices in these situations; to develop the necessary skills for moral deliberation in the face of ethical problems in primary healthcare, providing prudential, reflective, and considered judgments and allowing the arguments and counter arguments in a true dialogue of the team; to sensitize the healthcare professionals to evaluate the ethical dimension of their practice in primary healthcare in order to recognize the ethical problems and the values in conflict in these situations and put forward, in a responsible way, creative and sensible solutions; to highlight the importance of the mediations necessary for deliberation in bioethics, such as therapeutic communication, a helping relationship, and empathic listening.

LITERATURE REVIEW

Approaches for teaching bioethics

Moral life is not merely a matter of good will and correct intention. It also requires arduous and patient learning as does any other human ability⁽⁶⁾. There are two approaches for the teaching of bioethics: pedagogic and Socratic. The first is the most common. It is centered on the transfer of knowledge, focusing the teaching process from the elaboration, implementation and evaluation of a program. The second approach, without neglecting the rigor of the content, prioritizes the transformation of the being. This was what Socrates sought in dialogues with his disciples, hence the Socratic or maieutic approach. The teaching procedure of this approach is called maieutic, from the Greek maya (mother, midwife, the midwife's art)⁽⁵⁾. The Socratic maieutic view is to give birth to, to bring forth the best that people have within themselves. Socrates did not want to impose anything on the subjects, but to help them to give birth to the best they had in them. Everyone has to give birth personally, with the teacher, respectfully and patiently assisting the person in this process, as a midwife supports and accompanies the labor. The Socratic focus proposes to facilitate the interior transformation of the attitudes⁽⁵⁾.

In primary healthcare, the pedagogic option of problematization can facilitate the operationalization of the Socratic approach in the structuring of training in bioethics and contribute to awaken and/or consolidate in the professionals a commitment to co-responsibility for the health of the family, which results in the cultivation of welcoming, bonding and caring attitudes and dispositions. Problematization considers that, faced with the changes in the present world, the most important thing is not knowledge but the ability to detect real problems and seek unique and creative solutions. Thus, it is essential to develop the ability to ask relevant questions so that, understanding the reality, the individual can identify and resolve conflicts, generating transformations in an autonomous and responsible way. Problematization aims to develop the ability to observe the immediate surrounding reality as well as the global and structural realities, in order to detect resources; to identify problems that hinder the efficient and equitable use of these resources; and to find ways of organizing the work and the collective action to achieve it⁽⁷⁾. By seeking to awaken the ability to ask relevant questions from sensitive and accurate observation and comprehension of the quotidian and structural reality, and to find creatively transforming solutions, the Socratic approach and the problematizing option are brought together as deliberative bioethics teaching strategies. To deliberate is to ethically problematize situations of moral conflict, that is, the conflicts of values experienced in healthcare, to find alternative courses of action, indicated as the optimal option. It requires interpretation of the real data, of the facts in their meaning connections; an analysis of life events, of the historical and cultural facts in their interconnections⁽⁸⁾. To deliberate well it is necessary to know how to problematize the ethical context of the clinical cases. The Socratic approach must always exist in the teaching of bioethics. It is the antidote to indoctrination, manipulation, imposition, and also to the reduction of the formation to the mere transmission of information and moral instruction, practices that generate frightened professionals, who do not know how to act in the face of ethical challenges and therefore seek protection in the defensive practice⁽¹⁾.

The problematizing teaching of bioethics allows each person to become the agent of their own transformation and of the modifications in their care practice, enabling them to detect the ethical problems that arise from the quotidian reality, and seek original, creative, responsible and prudent solutions. This type of teaching of bioethics requires: small, interactive and participatory groups; approaches that are more practical than theoretical, including case discussions for the analysis of problematic situations of the quotidian activity in healthcare, not only of extreme and exceptional dilemmas that may be rare in the practice of primary healthcare professionals; discussion continued through debates based on the knowledge learned and shared in the professional experience and in the biography of the participants. From the proposal of problematization for the teaching of bioethics, we propose the model of deliberation as suitable for training in primary healthcare. Deliberation has the peculiarity of considering that the clinical situation includes the various aspects that contribute to it, from questions relevant to comprehending the facts and identifying the values in conflict. It aims to trace possible solutions and find the optimal course of action, which is what prudently leads to the greater solidification of, or less damage to, the values in conflict in the case. This article reports the experience of implementing a training course in bioethics for nurses and physicians from the Family Health Strategy in Santo André, São Paulo, based on problematization and deliberation, as the ethical theory and procedure for decision making.

METHOD

The training in bioethics proposal

The training considered the peculiarities of the professional practice and the care in Family Health in Santo André (SP, Brazil). It used the problematizing approach as a strategy for the teaching-learning of deliberation in bioethics⁽⁸⁾, in order to develop and integrate a knowledge and skills base to deal with the ethical problems in healthcare. Deliberation is the process of self-education, almost self-analysis, which aims to bring about the transformation of the professional practice with attitudinal changes. It allows one to interpret data and to establish connections of meaning in identifying and addressing ethical conflicts. From the clinical situation, the deliberative procedure provides the weighting and inclusion of the values and contextual factors that contribute to the situation experienced by the user, their family and healthcare team. Thus, the comprehension of the life experiences is broadened, creating an environment conducive for the attitudinal changes of the professionals, with responsible commitment to the moral and technical excellence of their practice and care.

The educational proposal of the training was aimed at developing the skills and abilities necessary for moral deliberation. Included among these are: differentiation of the specificity of bioethics, in relation to the Law and professional deontology, when addressing ethical issues; sensitivity to perceive the conflicts of values in primary healthcare; integration of the facts, values and duties in the foundations of the decisions; implementation of the steps of the deliberative procedure to arrive at consistent decisions, from the contemplation of possible courses of action; improvement of the language for the clear description of the ethical problems, of the conflicting values and of the courses of action; development of respectful and dialogical coexistence with different moral views. The training also aimed to awaken the professionals to the importance of knowing how to manage communication and listening skills to better deliberate on the ethical issues.

The training included five sequences of activities, in two moments of concentration, interspersed by one of dispersion. Through theoretical-practical activities, each sequence aimed to develop key concepts, skills and abilities essential to train the professionals in the deliberative procedure. The activities included group discussion about concepts, views and professional experiences; plenary sessions; case studies; application of the deliberative method exercises; reading and discussion of texts; dramatization; class summaries; and written exercises. In the first sequence, the key concepts of moral experience and ethical problem were worked with, aiming to discuss the differences between the concepts of ethical problem and ethical dilemma and to designate the moral experience, distinguishing the contexts of facts, values and duties. The second had deliberative bioethics as its key concept and aimed to present deliberation as knowledge of bioethics in the handling of ethical problems.

Moral deliberation, responsibility and prudence were the key concepts of the third sequence, which aimed to demonstrate how to operationalize the deliberation procedure. For this, a hypothetical case was used and the participants were urged to perceive that there are more than two possible alternatives for solving ethical problems. With this, it was hoped to go beyond the extreme for and against views and to find intermediate solution courses for the problem presented. The more prudent courses are usually in the intermediate space. The fourth sequence had the expanded clinical as its key concept and aimed to discuss the peculiarities of the professional-user relationship in primary healthcare. The last sequence focused on the ethical issues in the relationships of the team, noting the importance of resolving the moral conflicts in a reasoned way through means of assertive communication. Based on the key concepts, during the sequence of activities contents were addressed, such as: genesis, history, concepts and scope of bioethics; commonalities and specificities of moral languages, ethics, professional ethics, law and bioethics; the ethical and moral experiences, with the levels of the values and duties; moments of analysis of the moral act; the fallacies about bioethics; the virtue of prudence; moral responsibility in clinical practice; the peculiarities of bioethics in Primary Healthcare and Family Health. The first moment of concentration was followed by two weeks of dispersion, during which participants had to choose an ethical problem that they had experienced in their practice in primary healthcare and to prepare it for the sessions of deliberation that would be developed in the second moment of concentration. The total workload was 40 hours, with 30 hours dedicated to concentration activities: 20 hours for the sequences of activities and 10 hours for the sessions of deliberation.

To evaluate whether the objectives of the training had been achieved, the participation and involvement of the participants in the activities, the performance in the written exercises, and the presentation of the case for deliberation, were used. In order to estimate the mobilization of the sensitivity for the perception of ethical problems, an instrument for inventorying this type of situation in primary healthcare was applied before and after the training. For the overall evaluation of the training the participants were asked (06 physicians, 06 nurses and 01 dentist): What have you learned during the deliberation sessions of the course? How will the course influence your daily work practice?

RESULTS

The evaluation of the proposal

The professional participants reported that the course left them more confident to deal with situations of moral conflict, because they comprehended the need to analyze problems and situations from different points in order to visualize the various alternative courses of action before resolving an ethical problem. They might also have comprehended that the ethical dimension is inalienable from the clinical, since it also deals with the values involved in the situation, with it being necessary to analyze each case without prejudgment. They recognized that the exercise of application of the deliberative procedure contributed to them appropriating knowledge that would allow them to reach consistent decisions and debate the moral point of view. Regarding the course structure, the evaluations indicated the need to increase the workload of the second moment of concentration so that everyone can present their cases.

DISCUSSION

Learning ethics begins by imitation: Pedagogy of the example, hidden curriculum⁽¹⁾. If we consider that the basic health units are fields for the practice of the students, the continuous training in bioethics of the family health teams can have repercussions in the initial training of the future generations of professionals. The ethical, initial and continuous training of healthcare professionals is essential for excellence in care. This includes technical and scientific aspects of skill in the procedures, familiarity with the current protocols and the best evidence, as well as the ethical dimension. Without this, the best technical care may be perceived as being of poor or unsatisfactory quality. Indeed, the clinic loses quality if the interpersonal plane is ignored. The relationship between the professionals and users is not merely a bureaucratic or administrative proceeding, but the bond, the interpersonal encounter for the care. Therefore, ethical responsibility and commitment has to be incorporated into a dialogical clinical relationship that provides an exchange of values, feelings and beliefs, as well as the communication of signs, symptoms and examination data⁽⁹⁾.

The teaching of bioethics implies openness to dialogue, as the condition and result of the educational process. Bioethics is primarily the result of extensive dialogue between the various cultural and religious currents, in order to develop some consensus or achieve some balance regarding the critical and prudent evaluation concerning that which should be encouraged and that which seems inadvisable or intolerable for the present and future health of the populations, the Earth, or even for the dignity of the people⁽¹⁰⁾. The teaching-learning of bioethics aims to prepare professionals for this dialogical consultation within the context of their clinical practice and teamwork^(8,11).

To recognize the dialogical validity of the different positions and arguments drawn from different systems of moral thought does not mean being neutral. The training in values has usually been performed with two antagonistic trends: the imposed, which takes the values as something objective to be assumed by the individual, even at the expense of imposition, and the neutral, which considers the values as subjective entities about which rational argument is not worthwhile. Between imposition and neutrality, lies the deliberative model⁽¹²⁾ the object of the teaching experience reported. Deliberative habits require the mediation of means and instruments from other areas of knowledge, such as clinical interviewing techniques, emotional support, therapeutic communication, and a helping relationship⁽⁹⁾.

CONCLUSION

Problematization was shown to be effective as an educational strategy for teaching-learning in the continuous training of the professional in deliberative bioethics. The training developed with the family healthcare nurses and physicians of Santo André (SP, Brazil) was shown to be successful, in view of the positive evaluations of the participants, who considered the course enlightening, well prepared and that it provided support to improve their behavior and decisions in their work in the primary healthcare units. There is a need to extend the time for the practical application of the procedure of deliberation and to provide prospective follow-up meetings.

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Correspondência:

Elma Lourdes Campos Pavone Zoboli

Av. Dr. Enéas de Carvalho Aguiar, 419 – Cerqueira Cesar

CEP - 05403-000 - São Paulo, SP, Brasil

Publication Dates

• Publication in this collection
  04 Dec 2012
• Date of issue
  Oct 2012

History

• Received
  15 Oct 2010
• Accepted
  28 Mar 2012