Teaching strategies : promoting the development of moral competence in undergraduate students

Objective: To identify strategies and spaces used by professors to promote the development of the moral competence of nursing undergraduate students. Method: Qualitative research, developed with 20 nursing professors, through a semi-structured interview, from July to October 2016. Data were submitted to discursive textual analysis. Results: Three categories were constructed: Active methodologies as strategies for the development of moral competence; Knowledge and development of clinical reasoning as motivating spaces of moral competence; Attitude of professors as a strategy for dialogue, empathy, recovery of moral values and development of caring skills. Final considerations: The use of strategies and spaces to develop pedagogical actions favors the search for knowledge, clinical reasoning and the approach of ethical and moral aspects that collaborate for the development of the moral competence of nursing undergraduate students. Descriptors: Nursing Education; Moral Development; Professors; Students; Moral. RESUMO Objetivo: Identifi car estratégias e espaços utilizados por docentes para promover o desenvolvimento da competência moral dos estudantes de graduação em Enfermagem. Método: Pesquisa qualitativa, desenvolvida com 20 docentes de enfermagem, por meio de entrevista semiestruturada, no período de julho a outubro de 2016. Os dados foram submetidos à análise textual discursiva. Resultados: Construíram-se três categorias: Metodologias ativas como estratégias ao desenvolvimento da competência moral; Conhecimento e o desenvolvimento do raciocínio clínico como espaços motivadores da competência moral; Atitude docente como estratégia para o diálogo, a empatia, o resgate de valores morais e o desenvolvimento de habilidades para o cuidar. Considerações fi nais: A utilização de estratégias e espaços para desenvolver ações pedagógicas favorece a busca do conhecimento, o raciocínio clínico e a abordagem de aspectos éticos e morais que colaboram para o desenvolvimento da competência moral dos estudantes de graduação em Enfermagem. Descritores: Educação em Enfermagem; Desenvolvimento Moral; Docentes; Estudantes; Moral. RESUMEN Objetivo: Identifi car estrategias y espacios utilizados por docentes para promover el desarrollo de la competencia moral de los estudiantes de graduación en enfermería. Método: Investigación cualitativa, desarrollada con 20 docentes de enfermería, por medio de entrevista semiestructurada, en el período de julio a octubre de 2016. Los datos fueron sometidos al análisis textual discursivo. Resultados: Se construyeron tres categorías: Metodologías activas como estrategias al desarrollo de la competencia moral; Conocimiento y desarrollo del raciocinio clínico como espacios motivadores de la competencia moral; Actitud docente como estrategia para el diálogo, la empatía, el rescate de valores morales y el desarrollo de habilidades para cuidarlo. Consideraciones Finales: La utilización de estrategias y espacios para desarrollar acciones pedagógicas favorece la Teaching strategies: promoting the development of moral competence in undergraduate students Estratégias docentes: promovendo o desenvolvimento da competência moral em estudantes Estrategias docentes: fomentando el desarrollo de la competencia moral en los estudiantes


INTRODUCTION
Moral competence can be understood as the ability of individuals to make decisions and to issue moral judgments guided by their internal principles and then to act in accordance with such judgments (1)(2) .By educating morally, the formation of citizens with a more developed, autonomous, responsible and more cooperative moral consciousness is potentiated (3) .In this way, the possibilities of (re) constructing human capacity are enhanced, mediated by a pedagogical relationship in which both the professor and the student teach and learn, (re) building knowledge together (4) , and reconstructing themselves as people, and developing themselves morally.
The option for this theme occurred due to the observation of students who had difficulties in facing and resolving conflicts, making judgments and making decisions that involved values, ethical and moral conduct during the activities of the undergraduate internships.In the meantime, when searching the scientific literature for studies addressing the moral competence of students relating to teaching practice, a gap was presented in this area of knowledge, impelling the development of this theme in the present research.
It is considered that if the teaching-learning relationship between professors and students is based on the creation of spaces conducive to the development of moral competence, students, during their undergraduate course will improve their competence to face and decide ethical and moral conflicts, in a more coherent way using their values.Therefore, it is necessary to focus professors' concerns on skills, knowledge, innovative practices, and values, as well as on using spaces and strategies that accompany paradigmatic changes in nursing education (5) .
The construction of knowledge in nursing, in particular, is linked to the training of nurses, requiring the implantation of models based on professional competences, from an ethical and moral perspective.A competence is also capable of encouraging students' moral competence development, since it allows them to reflect on values and meanings that will support their actions and decisions to build a know-how, practical and linked to the ethical, social and political context (1) .
It should be emphasized that morality can be seen with a cognitive aspect, and that both morality and moral development cannot be reduced to moral and socialization attitudes, but must be understood as a component of competence.Thus, morality can be learned and improved, provided there are development strategies and spaces that allow such development (1)(2)6) .
Thus, the nurses' pedagogical training process requires the use of active teaching methodologies by the professors, capable of boosting the student's own reflection on their incompleteness.This process should be initiated by professors, who should mobilize students for reflection, favoring their growth and maturation, with discernment for a moral and ethical dimension (7) .
The moral and ethical dimension of doing/caring for, impregnated in the routine of the nurses' training process, is based on the close connection between ethics and education.This dimension is based on critical thinking, on the full development of the capacity for reflection, on the critical analysis of society and on the socio-educational relations of the subjects of this process (8) .
In this sense, ethical issues must permeate the teachinglearning process of the nurse, being fundamental for the construction of new practices, renewing the doing/caring for (7) , which reinforces the need for a constant transformation/feedback of the students and professors' actions (8) .Students recognize the good professor in those professors who, in addition to didactic knowledge, adopt practices that express a model and a way of liberal being/doing, without authoritarian attitude (9) .

OBJECTIVE
To identify strategies and spaces used by professors to promote the development of the moral competence of nursing undergraduate students.

Ethical aspects
The ethical aspects were respected, as recommended in Ordinance 466/12 of the National Health Council (Conselho NacionaL de Saúde-CNS), so that the study was approved by the local Research Ethics Committee.The professors' statements are identified by the letter D, followed by a sequential number (from D1 to D20).

Type of study
This was an exploratory and descriptive study, with a qualitative approach, carried out with 20 teaching nurses (total of 31) of a nursing undergraduate course at a university in the south of Brazil, of which 19 were female; age group between 25 and 64 years; nine had a license's degree for teaching; 15 had experience in practical assistance, 18 with doctorate, two carried out graduation internship and two were studying in a doctorate's degree course.As for the duration of the professional activity, six worked for less than two years, six between two and 10 years and eight had more than 10 years.

Methodological procedures
This is a semi-structured with recorded interviews conducted with an average duration of 50 minutes, containing closed questions for the characterization of the participants, and open questions focusing on ethical and moral aspects and strategies used by the professors to mobilize the development of their moral competence in the undergraduate student.
It was defined as inclusion criteria: working at the Nursing School and having, at least, six months of experience in the Nursing Course.The exclusion criterion was limited to any type of absence leave, vacation or attestation during data collection.

Study setting
The study was developed in the Nursing School, with professors of the Undergraduate Nursing Course of a public university.

Collection and organization of data
Data collection took place in the period from July to October 2016.The process of organization occurred with the transcription of interviews.

Data analysis
Data analysis was performed using the Discursive Textual Analysis (DTA) technique, understood as a self-organized process of construction and understanding, in which new understandings emerge from a recursive sequence, organizing arguments around four focuses: unitarization, the establishment of relations, the capture of the new emergent and a self-organized process (10) .The first three compose a cycle, and in the fourth process, the moment when new understandings emerge, called "building a self-organized process" it is an emerging process of understanding that began in the first stage of the analysis, with a movement of deconstruction of the corpus, following the end of the analytic process, in which an intuitive self-organized process of reconstruction was developed with the emergence of new understandings in the written form (10) .
From the data analysis, three categories emerged, according to Chart 1.

1-Active methodologies as strategies for the development of moral competence
The use of active methodologies, that is, the adoption of a process in which the student becomes the main agent of their development and learning was considered as a possibility to rescue the sensitivity of the student and to contribute to the critical thinking, making possible decision-making and humanized and ethical actions.
We have to boost all the time the reflection, active methodologies, a dynamic with a whole outcome so that the student can awaken their sensitivity to a more humanized and ethical care [.

Situations problems, active methodologies, that encompass reality, situations that you can experience and put to students. I think that through active methodologies, situations problems they can see enough and understand this perception, favoring the development and construction of them. (D11)
Among the mentioned methodologies, there are: case simulation; case studies; "Rounds"; workshops with ethical dilemmas; and realistic simulation.

We can turn it into drama, with case simulation. Simulate situations where academics act. this type of methodology is more participatory, involving students, which facilitates clinical reasoning and association between theory and practice, favoring ethical and moral development, and then critique and assessment. (D13)
We also work on case studies, which are fictional, invented case studies of patients.We always insert some ethical question in these case studies.(D3) The "round" was considered as a collective space for the approach of the different members of the multidisciplinary team, in order to favor and share experiences of learning and the exchange of knowledge.

One of the methodologies I use is case studies in the palliative care class, which I have been building for some semesters, it was only the terminality, then we have included palliative care, and now I have included the delivering of tough news. (D2)
Through "rounds" with discussions, grouping various sections of the hospital.I think these academics would not leave so helplessly ethically, like this.They would have their moral construction more solid.And perhaps this would greatly minimize future distortions that we know that happen.(D12) Making a "round" Calling the academics, so they put the cases they had during the week, the difficulties, the conflicts they perceived, and see the example of the other, to discuss and talk about possible solutions found, what would be the most correct conduct, how can we handle with the situation in a better way.(D14) When conducting workshops that involve ethical issues and provide the exchange of experiences in the face of ethical issues and dilemmas, the professor can elicit the internalization of moral values to promote the development of ethical and moral competences in the face of conflict resolution.

When I hold workshops and bring examples of conflicts and dilemmas, I show a film, a documentary with real situations to debate ethically and morally. (D4)
The freedom to think and reflect critically through realistic simulation as a teaching strategy provides the reflection of a clinical situation with real problems in learning approach, which is not always available in care situations.

Promoting a realistic simulation, with the student being patient is an important pedagogical practice with a situation that encourages, and makes the students to reflect and develop a critical spirit for decision-making. (D7)
We provide realistic simulation, with the students of the research group.They simulate a case, they act.Because there students consults, makes mistakes, talks, and then we give the feedback.All the students say, oh, professor, we could do this in each field of internship.(D17)

2-Knowledge and development of clinical reasoning as motivating spaces of moral competence
Knowledge and clinical reasoning as spaces of strengthening between theory and practice and as resources to develop cognitive and behavioral abilities was highlighted.
The classroom.Theoretical and practical.And often even the nursing laboratory.So that they can visualize and put themselves in situations.(D11) [...] when you build knowledge, ethical aspects are already set.When developing an interactive methodology, all parties plan.Because I see ethics in knowledge and in the planning of an activity.It is a moment of interaction where students are structuring, forming so that they quickly have a reasoning of planning and action.(D19) Clinical reasoning is presented as a capacity that allows students to question the self and the learning environment critically, causing them to elaborate their knowledge to apply to the real needs of the individual.

3-Attitude of professors as a strategy for dialogue, empathy, recovery of moral values and development of caring skills
Professors emphasized that ethical and moral values emerge during theoretical and practical activities, the attitudes they establish with students and the established dialogue in relationships with patients and other members of the multidisciplinary team.
When thinking about ethical competence, I think of training as human beings.We must make this dialogical process with the students, knowing how they would like it to be articulated, worked out.Starting from this conversation, from this mutual construction, a more pedagogical and systematized construction is possible.(D16)

Their decisions on how to act in the units, being empathic with the patient/family and the team has the influence of the professor, seeking the best way to pass the knowledge and experience to the students, and thereby influencing the student's ethical and moral conduct. (D5)
The socialization of knowledge in the environment of practical activities favors the integration of students with other team members, colleagues, professors, patients and family members, leading to the strengthening of moral values and the building of affective bonds, as stated below.

Learning to do, to be and to live together allows the socialization of knowledge and values. To understand how the team works, the different forms of work of each one, the colleague, the nurse, how to interact with the family member or with the patient, this all appears, comes out and becomes explicit. (D18)
You are already giving a basis, promoting, encouraging, and giving a contribution to face or have a little more capacities, solidity in the daily life, which is heavy!It's complex and difficult to give subsidies and strengthen the student, to face the challenges of the profession.(D20) The use of these spaces and strategies to develop the pedagogical actions of the professors studied seems to favor the search for knowledge, clinical reasoning and the approach of ethical and moral aspects that contribute to the development of the moral competence of undergraduate Nursing students.
From the results found, it is observed that the numerous strategies adopted in the Nursing training process, according to the professors, seek to develop and boost in nursing students moral competence.

DISCUSSION
In seeking to identify strategies and spaces used in pedagogical practices, in the development of their activities and in promoting the development of students' moral competence, professors brought the use of active methodologies, the domain of knowledge encouraging clinical reasoning, motivated by the teaching attitude to dialogue and to the rescue of moral values.
The use of active methodologies in nursing teaching represents an effective strategy for meaningful learning.By promoting the insertion of the student in the practical activities of health care, the professor can contribute to the awareness, beginning a progressive development of reflection and appropriation of reality, being able to transform it from its actions and the use of ethical and moral principles as the basis for possible conflict solution (5) .
In this way, the practice of case simulation and the discussion of case studies are presented as a space for student appreciation and recognition, as it becomes present and participatory, through the relation of theoretical and practical knowledge.The professor seeks to awaken in the student the search for knowledge through the description of a fact, encouraging a situation that is often present in the daily routine (5,11) , a strategy that allows the student to be the protagonist of his/her learning process through an active participation in the construction of own knowledge.It is a methodology that allows to work the knowledge and to improve the skills of the students, collaborating for the development of their moral competence; mobilize knowledge articulated to previous knowledge, favoring the development of skills and the internalization of moral values (2,(12)(13) .
In the use of the "round" as a moment to hold discussions of patients' clinical conditions, expression of opinions about care actions and therapeutic behaviors, a space is opened that encourages the questioning about values, which are based on their internal principles, contributing to issue judgments and decision-making regarding care, promoting clinical reasoning (2)(3) .The use of workshops to discuss ethical issues through the use of dilemmas allows the student to demonstrate weaknesses, strengthen problem solving, reinforce moral principles necessary for social well-being, and thus develop moral competence (1)(2) .In this perspective, it is possible to understand that nurses' training cannot be thought without the visualization of the ethical and moral perspectives that form the basis of their moral development (14) .
By using teaching strategies, the professor contributes to increase the quality of teaching and the production of knowledge, encouraging the active participation of students in the teachinglearning process, allowing them to develop competences for the exercise of a reflective and critical assistance practice committed to the care (15)(16) , evidenced in the practice of realistic simulation, which provides the student with the opportunity to seek knowledge and skills by boosting rapid thinking and teamwork, providing space for creativity, for the development of actions and moral attitudes (17) .
It is necessary to use strategies that can give the student moments with active participation in the discussion of ideas, boosting reasoning, problem-solving, the relationship between theory and practice, in order to transform learning spaces into environments with possible solutions for problems based on and founded in dialogue and joint construction, recognizing the critical capacity of the student and enabling the development of moral values (13,16) .
Reflective nursing education, being critical and attentive to the realities lived in the daily life of the profession brings the student closer to the professional reality and facilitates the theory-practice link, so important for the training of professionals trained to experience the profession, besides to enable the development of moral values, essential for care assistance (16) .
The simulation of a real setting for the exercise of care is the main space for ethical training, since it requires knowledge of how to deal with feelings and, with adversity, promoting the ability to work as a team and contributing to the construction of environments ethical issues where everyone can have an active voice (18) , creating opportunities for the solution of ethical and moral problems and conflicts in order to obtain effective results, attitudes that make a difference for those involved and contribute to the development of clinical reasoning (19) .
When the professor mobilizes the clinical reasoning through active methodologies, the student can perceive the moral commitment as essential in his/her formation, allowing the reflections made to contribute to the internalization of values, with positive reflexes not only in their behaviors, but also in the care provided; and nonetheless, in the construction of an autonomous and ethical health worker with theoretical-practical knowledge and professional competence, recognizing and valuing human care as part of the scientific world (16)(17)(18)(19)(20) .
As students rescue their sensitivity to care, attending to the needs of the users through clinical reasoning and with awareness of the need to issue critical thinking based on knowledge, they can develop a humanized and ethical care (20) .
Teaching strategies: promoting the development of moral competence in undergraduate students Enderle CF, Silveira RS, Dalmolin GL, Lunardi VL, Avila LI, Dominguez CC.
For professors, knowledge and clinical reasoning are not enough for the development of behavioral skills.It is necessary for the student to believe in its fulfillment, imbued with a sense of duty, responsibility and commitment in a process of building an ethical practice (7) .To do so, to question, seize opportunities and boost the reflection of values, standards, principles and ethical knowledge can base their way of being/doing and of relating with the other, contributing to the development of moral competence of the student (6,20) .
From the results of this research, it is possible to verify that professors have a pedagogical responsibility translated by their knowledge and life experience, made available to the students, so that together they can walk in search of the strengthening of this knowledge both in theoretical activities and in practices.In this partnership, it seems possible to provide a teaching environment conducive to dialogue, allowing its actors to freely express themselves in order to submit their opinions, suggestions and thoughts, to the judgment of others (6) .
Dialogue, teaching attitude, and respectful and empathetic relationship between professors and students are likely to provide moral development.Thus, professors have a constant influence on the moral formation and behavior of students through their behaviors, as well as the exemplification of standards and values, goals that must be formulated consciously in view of moral development (1) .
Empathy, understood as the ability to see things from the perspective of the other, along with attention to care needs, consist of strategies to bring out the sensitivity of the student.For the training of nurses with technical and relational qualities, it is necessary to offer subsidies that enable them to put themselves on the other's shoe (21) .Boosting empathy requires more than a theoretical and practical knowledge of the professor, that is, it requires the internalization of moral values, the search for moral competence to understand what is going on with the other, putting oneself in the others' shoe to "feel" with the same intensity their needs (8) .
The training of the nursing student, based on pedagogical actions aimed at the use of active and dialogic methodologies, seeks to implement ways of constructing a participatory education, in which students develop their moral competence as a way to contribute to the changes that the current society requires by acting with autonomy, efficiency and effectiveness in health services (5) .

Study limitations
It is emphasized as a limitation of the study, the fact that the research was only developed in one reality.It is suggested to expand to other Higher Education Institutions, including private education.

Contributions to the sectors of Nursing, Health or Public Policy
The study brings contributions to Nursing, as it shows the importance of undergraduate education in the moral development of the student and the important contribution of the professor to this growth.

FINAL CONSIDERATION
Through this study, it was possible to identify that professors, when using active teaching methodologies, consider the importance of knowledge as an ally with the development of clinical reasoning, and institute dialogue and the recovery of moral values, are contributing to promote the development of moral competence of students.
It is believed that the development of these strategies provides the construction of spaces that break with traditional teaching, encouraging students to seek new knowledge and learning, deepening seized contents and enriching the exchange of knowledge.Likewise, professors feel challenged to innovate, to exchange knowledge, through active teaching methodologies, boosting clinical reasoning, dialogue and the rescue of moral values.
It is possible that the search for knowledge and the development of ethical attitudes and actions constitute the basis of the professor-student relationship, allowing the articulation of theory and practice together.This path contributes to a significant pedagogical practice, in which learning comes with more pleasure and enthusiasm.From this perspective, professors emphasized the need to instigate the student through the innovation of their practice, be it exploring spaces other than the classroom, or searching for new ways of learning knowledge.The acts of listening, discussing, evaluating and dividing opinions in search of a consensus, as emphasized by the professors, allow the student to develop the ethical conduct necessary to guide their actions and make decisions.
Teaching strategies: promoting the development of moral competence in undergraduate students Enderle CF, Silveira RS, Dalmolin GL, Lunardi VL, Avila LI, Dominguez CC.
Chart 1 -Structural model of construction of the categories, Rio Grande, Rio Grande do Sul State, Brazil, 2017 Teaching strategies: promoting the development of moral competence in undergraduate students Enderle CF, Silveira RS, Dalmolin GL, Lunardi VL, Avila LI, Dominguez CC.