Active methodologies as strategies to develop education in values in nursing graduation

Abstract Objective: To reflect how active learning teaching methodologies are important strategies for teachers to work on education in values in nursing graduation. Method: It is a reflection, therefore, as theoretical reference it was used the productions of the Group of Research of Moral Education of the University of Barcelona (Spain). Results: Active methodologies contribute to create conditions that enhance moral sensitivity, situations that allow the living of moral conflicts, stimulating dialogue and scenarios that allow the recognition of difference, favoring the construction of consensus. There are numerous strategies of active methodologies that contribute to the moral formation of the individual, but this article will focus on the main forms problema based learning (PBL) and the methodology of problematization. Final considerations and implications for practice: It becomes indispensable to transform theoretical foundations on education in values into viable pedagogical practices for their implementation in nursing curricula.


INTRODUCTION
In conversations among teachers, the complaint about the student not being the same as before is frequent. So, if students changed, why do pedagogical practices are still rooted in educational ideas from the 20 th century? Have these teachers reflected on their classes and on the way of teaching they have been using? Buxarrais 1 endorses the critique on the current educational system, claiming it was planned and structured in a past epoch and, thus, it values individual effort, memorization, homogeneity and alienation, reinforcing the productivist logic. In contrast, values such as creative thought, bond and care are neglected in teaching.
Excelence in care is recognized as a pillar on nurses' training and, for this to occur, it is needed to promote technical and scientific competences but also relational skills. Nursing is still constructing it's profissionals' groundwork; thus, the need to afirm itself in the market results in excessive preocupation with specialization, 2 valuing technical and scientific knowledge, evidenced by the enphasis given to biological issues in the health-ilness process -, known as biomedical model -to the detriment of psycho-affective and socioeconomic issues, that provokes a marginalization of moral discussions.
Adding to the critique of the biological model still in force in a scenery of excessive creation of nursing courses, there's low quality of teaching 3 and to moral values in crisis in the current society, 1,4-7 the training of the nurse is questioned.
Study by Lopes, Azeredo and Rodrigues 8 identified skills nursing students consider important for nursing training. Knowing how was valued, more specifically, the appreciation of procedures and techniques. This fact is worrisome, because the nursing professional can develop an specific technique with perfection, but not be respectful to the health user, which characterizes oneself as an unqualified professional to practice the profession, once it's necessary to know, to know how todo and to know how to be.
Thus, working with moral training in the undergraduate program of nursing enables the student to comprehend the responsability of his/her profession, that has on it's essence the care for the other, an individual with other values and beliefs. It becomes evident, therefore, the professional-user relationship, the need for respect, dialogue, bond, that must follow the technical knowledge, since mastery of cognitive knowledge for effective care also demonstrates respect and commitment to others.
For this integral training to happen, Ministry of Education (MEC) 9 instituted, in 2001, National Curricular Guidelines (NCG) of the undergraduate course, instrument of pedagogical practices, outlining professional profile that are expected to be trained, assuring the use of methodologies that stimulate reflection on social reality and that promote the learning to learn. Therefore, banking education, 10 considered that in which the teacher is the knowledge holder and deposits in the students several knowledges, in a fragmented form, passive and acritical, it's not enough to the individual's moral formation, once the promotion of moral values must be developed beyond theoretical activities proposed in the classroom. Experience and discussion of ethical issues must permeate the whole curriculum, in a cross-sectional way, forming the guiding axis of school culture.
There are several pedagogical practices that contribute to the individual's moral formation, such as learning in the service (ApS), the construction of reflexive narratives, discussion of moral dilemmas, case study, problematization methodology, learning based on problems (LBP), among others. 11,12 These are some strategies of active methodologies of teaching and learning that stimulate the student to adquire skills, not just techniques, but also humanistic and ethical ones.

Aim
This article's aim is to reflect on how active teaching-learning methodologies contribute to education in values for nursing students and offer subsides to it's utilization in the undergraduate program.

Method
It's a theoretical reflection and, for such, we used as theoretical referential the concepto f moral education, from the Research Group of Moral Education (Grup de Recerca en Educació Moral -GREM), from the University of Barcelona. GREM is part of an Education Faculty, it emerged in 1988, it works with the concept of education in values and, nowadays, it's production is recognized in the academic world. It has a research line called "Ethical learning and university", in which it acts rethinking the university mission in the 21st century, with the ethical and moral focus, identifying dimensions that construct the moral personality and ethical competences of universities; developing proposals to feed ethical skills in universities and analyzing the impact of learning based on social responsability and commitment that university has with society and it's preocupation to form citizens. 13

Education in Values
Martínez, Esteban and Buxarrais 14 suggest three peoposals to assisto n developing education in values: working the student's autonomy, working with the concept of school as a community and stimulating the pluralism as a value.
The teacher must promote the student's autonomy, valuing individual pecularities through diversity present in the classroom and, at the same time, stimulating students to choose moral values related to the community they are a part of, that is, related to traadition. 5 Stimulating autonomy so that students choose moral values without relating them to the tradition is a risk, once the aim is to construct more just societies; this, individual moral values and communities must be allied. 14

Active methodologies and education in values
Marques LMNSR The concept of tradition, according to MacIntyre, 5 is referred to the set of pratical knowledge that justify constumes of a group, transmitted through generations. It believes that the moral subject must be inserted in a tradition because that way one acquires reference in relation to needed virtues to live in community, such as justice, trust, generosity and patience.
At the same time the school must stimulate student's autonomy, it must promote respect to other cultural groups, constructing the concept of school as a community. Martínez, Esteban and Buxarrais 14 defend that, to occur education in values, one must work with an intercultural education, in order to potentialize harmonious coexistence among groups. Through moral education, individuals must understand that human beings are vulnerable beings and this generates a mutual dependency among them; thus, helping the other must be worked as a moral duty and not as an individual preference.
MacIntyre 15 also wrote about the importance of people to comprehend mutual dependency among them, in response to the fragility of the community ties arising from modernity. As a consequence of this fragility, a fragmented society was developed and with simulacra of morality, a present challenge until today.
To train individual belonging to a plural worl, firstly one must learn community's values so then the teacher promotes dialogue and respect among different ones. Pluralism must be conceived as a value in school. Therefore, education in values intend to train authentical individuals because, even after present certain moral horizons that guide the well being of the community, students can ellect those values they identify themselves. Promoting pluralism is promoting respect, tolerance and justice. 14 Thus, educate in values Consist in creating conditions that potentialize moral sensibility, situations that enable experience of moral conflict, stimulate dialogue and scenery that enable recognizing differences, favouring constructing consensus. 14

Active methodologies of teaching-learning
Active methodologies are ways of teaching that use real or simulated experiences, aiming stimulating solution of challenges from social practice, in different contexts, and that enable formation of active, critical, reflexive and ethical individual through meaningful learning. 12 The new emphasis given to the process of learning through the action comes from the influence of the North american philosopher, psychologist and pedagogue John Dewey, whose ideas arrived in Brazil through Anísio Teixeira. 16 Active methodologies bring the student to the center of the educational process, raising one's responsibility in relation of one's training. Therefore the role of the teacher also suffer changes, he in encharged of presenting the world to the student and, at the same time, leave one walk alone. Considering a world in Constant changing, traditional teaching that aims transmitting knowledge loses space, because Professional profile required by the work marker begins to value not only technical knwoledge, but also abilities of communication, interpersonal relationship, posture, among others.
There are many possibilities of active methodologies and, in nursing, he use of these pedagogical practices are being highlighted, mainly after NCG. However, there are still several mistakes as for it's application, having many times divergences between what pedagogical practices describe and the way they really happen, therefore, more discussion is needed. In this article, the main forms of active methodology will be presented: Problem Based Learning (PBL) and problematization methodology.
PBL is a learning method that works with problem situations, ellaborated previously by a team of teachers, that aims to stimulate cognitive processes in relation ot a determined subject. Problems are carefully planned by a commision that aims to integrate theoretical contents and are distributed in the curricular matrix according to a learning sequency, that is, with growing complexity degrees.
PBL happens in tutorial groups, from 8 to 10 students. The problem is presented and, in a first moment, students must discuss about the case, exploring previous knowledges and raising issues about learning. In a second moment, students devewlop individual studies, outside the tutorial section, seeking to answer questions raised after the first approach with the case. Lastly, students return to the group and rediscuss the problem in light of adquired knowledge. 17 This, PBL composes a main theoretical learning axis of the curriculum, having more disciplines in the curricular matrix, not being able, this way, to be just a methodology choosen by a teacher. PBL is an institutional option, because it requires curricular and structural changesarrange libraries, laboratories, provide a bigger number of rooms, hire teachers trained in this methodology, program free time for studying, "break" with disciplines, among others.
It is worth highlighting the difference among PBL, case study and moral dilemmas discussion. The last ones also work with situations-problems and can be used in isolated disciplines, because they depend on the teacher's pedagogical plan, being on his criteria to use one or more situations/cases throughout the discipline. Case study works with clinical or organizational situations and generally is used before the theoretical stufy on some theme, as a triggering situation for the presentation of the programmed content, that can be followed by a dialogued class, providing texts for the discussion in groups or raising learning issues and requiring individual searches. The discussion of moral dilemmas presents situations in which there is necessarily a conflict between moral values, requiring moral deliberation by the student, so it is widely used in disciplines of ethics and bioethics.
Problematization methodology uses the Charles Maguerez Arch, it is applied to pratical themes, related to life in society, it also happens in small groups and it develops in five steps: reality observation, key-points, theorizing, solutions' hypotheses and application to reality. 18 The first step is observation to social reality, with watchful eye and registering what is perceived. The teacher may direct observation to certain issues and students will be able to identify difficulties and discrepancies present in the studied reality. On the second step -key points -academics should reflect on the possible causes of the problem experienced

Active methodologies and education in values
Marques LMNSR and chosen for study. They will be capable of realize that problems are complex and need theoretical deepening, which implicates in learning issues. The third step-theorizing -is the search for diverse information that will help on comprehend the problem. The fourth one is constructing solution hypotheses for the observed reality, after group discussion with theoretical foundation. E, lastly, the fifth step involves execusion of decisions made in a group, applying these hypotheses to reality, aiming to transform them to some degree. The exercise of the dialectic chain action-reflection-transforming action reinforces the student's social commitment to the environment. 18 The problematization methodology has great potential to approach social and human issues, that are essential to the characteristic nursing process of caring. It is intended to prepare the student to be conscious about the world around him, making him act intentionally, with the aim of transforming society through a more dignified and just envirornment. 18 Different from PBL, the problematization method can be used in determined disciplines, independently from curricular structure, because it doesn't require physical or material changes in the school; thus, it can be a pedagogical option from the teacher, as long as he changes his posture. Another difference related to PBL is that problems are identified by students from an observed reality; therefore, there are no restrictions as far as content to be learned, once social reality is dynamic and complex. 18 Another important caveat is the difference between using a problematization methodology and problematizing a discussed content. Problematizatize means to instigate the student on knowledge construction, therefore it is a teaching-learning strategy on diverse active methodology forms. The methodology of problematization uses necessarily steps from the Maguerez Arch.

Interfaces of Education in values with active methodologies
Interfaces of Education in values with active methodologies will be presented, once the first seeks to promote autonomy, the concept of school as a community and pluralism and active methodologies enable the formation of an active, critical, reflexive and ethical professional.
The first interface to be discussed is the relation between active methodologies and promoting autonomy. Active methodologies stimulate autonomy when they put the student in the center of pedagogical process and, thus, co-responsabilize him by his/her learning. Both in PBL and in the methodology of problematization, the student is motivated to construct his/her knowledge, and it is up to the teachers to instigate and facilitate the way.
In order for the promotion of autonomy to be effective, it is necessary that the student is personally committed, experience the horizontal relationship with his/her teacher and has flexibility in executing proposed tasks. 12 Personal commitment can be worked through motivation, on being enabled to him a meaningful learning, that is considered the base of active methodologies. Horizontal relationship between the teacher and the student also contributes to motivation, because to incentive, praise, point errors and show oneself willingly to assist him facilitate interest by the discipline. This proximity is only possible to work in small groups, because it enables the teacher to identify educational gaps of each student and therefore promote deal learning with individual needs.
Flexibility shows in several moments of using active methodologies, enabling students to come up with constant choices and decision making. For exemple, they enable flexibilization of some content to be discussed, once each group present previous distinctive knoweldge, differing, then, in elaborated learning issues and even in the choice of days to answer them in group, or even related to pratical activities to be organized, in case of problematization method, because each pratical field has it's specificity; therefore a group can opt to work with health education with elderly and another with children. Going beyond, when the teaching institution enables, students can help construct an activity cronogram, agreeing on work deadlines, days of final evaluations, time of begining of classes, rules of tolerance for delays, among other ways of flexibilizations that raise the student's responsabilization in it's teaching-learning process.
Still discussing promotion of autonomy through active methodologies, the student is stimulated to develop responsibilities, being of groups or individuals, becoming important to be assiduous and punctual. On working with small groups, students realize that the participation of each participant is fundamental to construct a collective knowledge; therefore, it notices that his commitment has a direct relationship with the final result of all, which encourages in him the sense of responsibility. The same way, it happens when students are inserted in professional practice and enable care of nursing in health users, according to it's complexity level. These experiences demand some degree of intervention, stimulating responsibility to th health of those users.
The second presented interface is the relation of active methodologies with the concept of school as a community. Once more it is evident the importance of working with small groups, once this potent pedagogical strategy amplifies the possibility of more solidary relationships on making the student learn to construct ideas collectively, beyond enable dialogue, communication, integration and cooperation between different ones. 19 To estimulate harmonious coexistance inside the school is primordial so that the student also respect other groups outside the school, as the health team and users. When inserting the student in the professional practice, he learns the importance of interdisciplinary and intersetorial work, essential for intergrity of care, as well as the importance of bonding in the relationship professional-user. These experiences promote reflection that there is a mutual dependency among human beings, comprehended to recognize oneself that each health professional has his part in the care and that stabilished bonds

Active methodologies and education in values
Marques LMNSR maintain themselves in an exchange relationship, stimulating the value of communitary bonds. The third and last interface of active methodologies with education in values in promoting pluralism. This relationship is complementary to the discussion of concept in school while a community. To favour respect to different, stimulate reflections about other points of view, being in contact with several socioeconomical realities are attributes contemplated through active methodologies, either because they give the opportunity to work in a group, to insert the student in health units in peripheral neighborhoods or for enabling moral dilemmas discussions.
To many students, work in group is a new process, that generate resistances, because dealing with another requires learning different skills, such as accepting differences, learning to listen, learning with the other can also teach and learning to speak in a group. Therefore, it doesn't mean to work without conflits, it means to work with respect through diversity. 19 Puig 20 discourse about the importance of experiences in the life of an individual, raising, thus, the probablity of acing moral conflict situations. In order for the perception of the moral problematic to occur, in addition to providing the experience, the teacher must give rise to situations that arouse sensitivity and dialogue. That's why, concretization of moral education implicates in inserting students in sceneries that there is socioeconomical and cultural contrast, preferably out of school, in order of them to experience, problematize and, then, mobilize themselves to transform that reality.

The teacher
Being a teacher requires ethical and social commitment and, therefore, it must be aware of the grandiosity of one's role, once he's responsible not only by training professionals but also because he has the mission to contribute to the development of the personality of future adults in society. 16,21 That way, education in values prevails for constructing bonds between the teacher and the student. An authentic relationship that enables the teacher to welcome, recognize and acept the student, stimulating dialogue and helping him on what's needed, stabilisihing, that way, a trust relationship. Once created the bond, this tends to become a value for the student and the educator to promote discussion on moral values with a greater probability of, in fact, students rethink their conducts, because of the feelings attributed to the relationship. 22,23 In addition, the interpersonal relation has an irreplaceable character in the formation of the morality. 22 The teacher is seen as a source of inspiration; he must also teach values acting morally, that is, being a model mediated in the practice of moral actions, acting as a good person, because consequently he is teaching morality. 24 Interpersonal relationships are part of the whole educational process and are impregnated with values; that's why, they are educational practices considered cross-sectional and omnipresent and should therefore be planned and reflected. 22

The curriculum
Another form to make education in values feasible is through the so called curricular tasks. They can be disposed in a crosssectional way, on diverse disciplines, condensed in a few, such as the case of ethics and/or bioethics, present in nursing curriculum. What is important is that the curricular tasks of education in values have a defined and delimited time frame for such. 22 These disciplines must offer a space to welcome group's worries, to treat issues make the group uneasy and to talk about social relevant problems. That said, the next step should be to assist in moral deliberation, that is, to provide the use of moral intelligence by constructing moral arguments in the face of conflicts of values. 22 It happens that spaces provided in the curricula for these disciplines most of the time are reduced and overcharged with theoretical content, not leaving time for other reflections that can exist in that group. Another problem is the form these contents are approached: frequently in an expositive way, without promoting spaces for dialogue and construct consensus. Therefore, the defense is for institutions value more disciplines potentially turned to education in values.

The institution
Lastly, permeating all the bonds and the curricular tasks directed to the education in values, it is necessary to create a moral culture, because it is recognized that the institutional environment also contributes to the formation of the individual.
Moral cutlure incides on students' habits and virtues, because, once immerse in expressed values by institution, this invites them to experience them in their daily life, making it possible to cristalize them. Institutional educational practices must be coherent, involving didactics and coexistence to the organization of moments of fraternization and extra-class projects. 22

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE
Since active methodologies contribute to the education of values within the curriculum, promoting desired characteristics for future nurses, it becomes indispensable to transform the theoretical foundations on education in values into viable pedagogical practices for its implementation in the nursing curricula. However, implementation of the step by step of these methodologies is not enough to obtain success in training, it is necessary to have a director and teaching body engaged in training citizens. Forthat, it's indispensible that they appropriate themselves of knowledges from philosophy, antropology, sociology, pedagogy, among other areas of knowledges, which may occur through capacitation way. In addition, it is necessary that this training is not on time, but that it is part of the work process, with frequent meetings so that the teachers can expose their doubts and anxieties, since the great majority of the faculty members were educated in teaching traditional, and when faced with active methodologies, it is natural to face difficulties.

Active methodologies and education in values Marques LMNSR
In order to stabilish a horizontal relationship between teacher and student, as valued as inside active methodologies and education in values, is needed to care for relationships betweens leaders/teachers and teachers/teachers, because these reflect the way the teacher welcomes (or not) the student.
Lastly, education in values must crosspass disciplines of ethics and bioethics, it must happen in a cross-sectional way, composing the guiding axis of the curriculum. Concerning education in values in the nursing curriculum is to train, besides competent professionals committed to the health area, citizens engaged in the construction of a more dignified and just world.