Ethical competences for the development of nursing care

Objective: To present an analysis of the nursing ethos based on the disciplinary foundations of nursing to propose a defi nition of ethical competences for nursing training. Method: The present proposal is a theoretical refl ection, based on a literature review of the specialty, both nursing and ethics. Results: we suggest basing the ethical education of nursing students integrating transversally disciplinary, bioethical and civic ethical competences, considering certain educational dimensions that favor their development. Final considerations: We expect that the defi nitions of three competences of the moral scope of nursing, contribute to cross-cutting proposals that promote the values and principles of the profession. Descriptors: Ethics; Nursing Care; Ethics in Nursing; Education in Nursing; Bioethics. RESUMEN Objetivo: Presentar un análisis del êthos de enfermería en base a los fundamentos disciplinares de ésta, a fi n de proponer una defi nición de competencias éticas para la formación en enfermería Método: La presente propuesta es una refl exión teórica, fundamentada en una revisión de literatura de la especialidad, tanto de enfermería como de la ética. Resultados: se sugiere basar la formación ética de estudiantes de enfermería integrando transversalmente competencias éticas disciplinares, bioéticas y cívicas, considerando determinadas dimensiones educativas que favorecen su desarrollo. Consideraciones fi nales: Se espera que las defi niciones de tres competencias del ámbito moral de la enfermería, contribuyan a propuestas transversales que logren fomentar los valores y principios de la profesión. Descriptores: Ética; Atención en Enfermería; Ética en Enfermería; Educación en Enfermería; Bioética. RESUMO Objetivo: apresentar uma análise do êthos de enfermagem em base aos fundamentos disciplinares desta, a fi m de propor uma defi nição de competências éticas para a formação em enfermagem. Método: a presente proposta é uma refl exão teórica, fundamentada em uma revisão de literatura da especialidade, tanto de enfermagem como da ética. a presente proposta ė uma refl exão teórica, fundamentada em uma revisão de literatura da especialidade, tanto de enfermagem como de ética. Resultados: sugere-se basear a formação ética de estudantes de enfermagem integrando transversalmente competências éticas disciplinares, bioéticas e cívicas, considerando determinadas dimensões educativas que favorecem seu desenvolvimento se sugere basear a formação ética de estudiantes de enfermagem integrando transversalmente competências éticas disciplinares, bioéticas e cívicas, considerando determinadas dimensőes educativas que favorecem seu desenvolvimento. Considerações fi nais: espera-se que as defi nições de três competências do âmbito moral da enfermagem, contribuam a propostas transversais que consigam fomentar os valores e princípios da profi ssão. Se espera que as defi nicões de três competências do âmbito moral da enfermagem, contribuam para propostas transversais que consigam fomentar os valores e princípios da profi ssão. Descritores: Ética; Cuidados de Enfermagem; Ética em Enfermagem; Educação em Enfermagem; Bioética. Josephine Karla Anna Bratz E-mail: josekb69@gmail.com CORRESPONDING AUTHOR


INTRODUCTION
In this study we carried out an analysis of the disciplinary bases of nursing to define three competences: disciplinary ethical competences; bioethical competences; and civic ethical competences, which make up the professional ethos.Thus, we expect to contribute to a greater clarification of the ethical competences that must be addressed in the nursing training plans.We propose that during graduation the promotion of the three defined be considered to avoid that ethics be presented as a great generic competition.In the opinion of the authors, competition hinders the progression of learning outcomes related to this field through curricular activities.We hope these three interdependent competences favor a more systematic graduation process.

DISCIPLINARY BASIS OF THE PROFESSIONAL ETHOS
Internalizing the professional nursing ethos during graduation requires a constant revision of people's own values, constructed from a personal biography, which must interact with the inherent values of the discipline.This is sometimes a difficult task, since it demands a capacity for introspection and self-analysis to allow advances in personal moral development, thus making nurses capable of integrating the professional ethos with the staff.The nursing professional ethos seems to have been outlined through centuries of care practice.It presents the nursing field since the second half of the twentieth century as a fruitful theoretical activity, which conceptualizes care, and characterizes the profession with discipline through the construction of models and theories, to guide an outstanding nursing practice (1) .Paradigms (of categorization, integration and transformation), knowledge, theories and nursing models contribute to the definition of their ethos and are determinant when defining the theoretical, practical and ethical competences that nursing professionals should develop to deliver care.Nursing paradigms are based on the relation established with four fundamental concepts, also called metaparadigms: care, person, health and environment.Such relation has evolved, adapting to the needs that have arisen in the environment, in which the delivery of care is inserted (1) , thus improving the principles and values of the subject itself.Socio-political changes that took place since the 1970s and the growing globalization (1) presented new challenges for health professionals to integrate social, economic, cultural and political aspects.Previously, they were not necessarily part of the knowledge and professional practices, making the paradigm of change emerge.In this paradigm, the metaparadigm person is considered an indivisible whole, that participates actively in their care and that coexists in an interactive and continuous relation with the environment.Person and health are an inseparable unit in constant interaction, change and evolution (1) , highlighting the importance of well-being and realization of the potential of each individual (1) .Professionals must communicate and exchange with the environment of the caregiver, displaying dialogical abilities that allow them to see other people's, which can differ from their own.Under an ethical perspective, applying this paradigm to professional practice implies developing competencies that allow nurses to establish symmetrical therapeutic relationships based on the recognition of the moral autonomy of others to care, promoting health together.Moreover, this paradigm requires professionals to recognize the relevance of the social, political, cultural and economic conditions of the environment in terms of its impact on the processes of health and illness of people.This demands us to consider these conditions in the professional practices and in the management of care.On the other hand, in 1978 Bárbara Carper establishes the fundamental knowledge patterns of nursing, which she determines as empirical, aesthetic, ethical and personal (2) .For Duran de Villalobos (3) , personal knowledge is considered basic for the development of the ethical and aesthetic, with special importance if we consider nurses as a therapeutic being that relates to others, who are under their care, in an interpersonal process in which the quality of this relationship and the established communication impacts on the way people face their state of health and illness.Achieving this quality therapeutic relationship and fully understanding others' experiences, requires professionals, first, to have a deep personal knowledge.This is gained through a dynamic process, experiences and, also, intuition, valuing themselves and others, with body-mind and spirit and also immersed in a cultural context and social system (3) .Regarding the ethical pattern of knowledge, both Carper (2) and Durán de Villalobos (3) highlight the inherent obligation of professionals to continuously guide the practice in terms of service to people and respect for human life.These characteristics of the relationship among nurses and their patients highlight the need for professionals to be able to consider individual contexts and respect the autonomy of people at the time of establishing moral judgments that guide the practice of care, even when they face ethical problems.Thus, the close and continuous relation between personal development (especially moral) and the assumption of professional ethical practices is seen as an aspect that must be considered paramount during professional training.As elements of the relationship between the nurse and the patient, White (2) , points out the intersubjectivity inherent in all human interactions; emphasizing the need to promote cooperative efforts based on the wills and values of the caregiver in clinical relations.This is a moral ideal, not a duty or a norm; but a moral initiative that must be manifested in the form of commitment in every relationship between nurses and caregivers.White (2) also proposes a fifth pattern, the political, focused on the environment in which a given experience of care is experienced.White (2) affirms that this knowledge abstracts care of self-absorption limited to the specific clinical relationship (nurses and their patients) and places it within the broader contexts and scopes.That is, health care occurs in a general way and nursing care in a particular one.This may lead professionals to analyze and eventually question professional practice, the profession and health policies (2) .This requires that professionals can analyze critically, against the socio-political environment in which care is inserted, to understand and engage themselves with the needs of societies to which professionals must respond.This is for them to continue legitimizing themselves, through a permanent dialogue with those really affected by their services, focusing on the real needs of caregivers belonging to a certain society.Along with creating paradigms, metaparadigms and nursing knowledge, various models and disciplinary theories have been developed and evolved, with elements that contribute to design the professional ethos.This brings to light the perception that care must be based on intersubjective relationships and effective forms of communication.Jean Watson (4) , for example, in her philosophy and theory of transpersonal care states and deepens the several of ethical competences, already visible in the analysis of nursing knowledge patterns; they are the willingness to achieve self-knowledge both professionally and on their own system of values, their spiritual dimension and personal need to encourage personal development.Professional evolution can thus, always occur in pursuit of a moral commitment to oneself and others, establishing relationships between nurses (watching them to be empathic, sensitive and sincere links).This must happen while identifying others' needs with mutual trust; and, in addition, in the care and management of individual care settings.Care process is exercised consciously through an affective relationship supported by the deployment of communication skills (4) .In consideration of the disciplinary elements discussed so far, it seems possible to assume that nursing professionals (and thus students under training) should develop moral competencies in various fields to comply with a practice of excellence.It can be defined as: disciplinary ethical competences, bioethical competences and civic ethical competences.

DISCIPLINARY ETHICAL COMPETENCES
Some of the disciplinary ethical competences required in this profession have been explicitly consolidated in the ethical codes of nursing; The Code of Ethics of the International Council of Nurses (5) (CIE) is established as a guiding code, which establishes the four fundamental duties of nurses: promoting health, preventing illness, restoring health and alleviating suffering; duties that come together in the primary responsibility of the profession, i.e. care, should be based on respect for human rights, the right to life and free choice, safeguarding the dignity of people, who must always be treated respectfully.CIE (5) highlights the importance of interdisciplinary work and equipment for the coordination of care and requires nurses to assume, along with society, the responsibility of fulfilling social and health needs of citizens, especially those of vulnerable populations (5) .Furthermore, it defends a fair and equitable distribution of funds in favor of access to health care and other types of social services; and to protect the environment (5) .It must also always ensure the quality of care, and continuous training in ethical matters.The deontological code can be a guide to act on social values and needs.In accordance with the paradigm of transformation, the meaning of this code only makes sense if applied taking into account the real contexts facing nursing care in a changing and globalized society.Beyond codes, there are multiple texts from different authors, which aim to describe, analyze and define from the disciplinary bases of nursing moral values and behaviors every professional should internalize and apply.The Spanish philosopher Francesc Torralba has deepened this analysis from the philosophical perspective and defines the care the duty of the nursing profession (6) .Torralba affirms that the concern for vulnerable people requires caregivers to develop the virtue of responsibility; and points out that the ethical foundation of caring lies in the recognition of the other (vulnerable) and the relationship with this other (vulnerable) can only be based on responsibility and solidarity.Because of that, according to the author, care requires "moreover, on competent care, individual care, emotional handling, sensitivity, personal complicity, confidentiality, proximity of ethical order, which also requires great communicative skills and psychological knowledge, a certain moral character, a professional ethos" (6) .The construction of this professional ethos demands, in turn, the development of certain virtues to build a personal ethos that is reflected into the professional ethos, an idea that reinforces the approach on the relationship between the ethical and personal knowledge analyzed by (2)(3) White and Durán de Villalobos.According to Torralba (6) , every nursing professional must develop five fundamental virtues, which he defines, following Roach and Brykczynska, as the ethical constructs of caring: compassion, competence, confidence, confidence and conscience (6) .It is evident that a practice of excellent care should be based on criteria of intersubjectivity, exchange and real commitment to the experiences of the other (or others) to care for.The awareness of the scope of practice itself, that is, the effect it has on patients, often vulnerable, must be the cornerstone that guides the reflection and action of the caregiver at all times (6) .The ability to have intersubjectivity appears again as an urgent competence to develop in each nursing training.Nonetheless, disciplinary ethical competences are now defined as: those that allow professionals to practice care with excellence (that is, based on the virtues, values and principles established by the subject), integrating in a consistent and differentiated way theoretical, practical and ethical knowledge, in different contexts that require decision and action.This must always consider a symmetrical and committed relationship between professionals and patients; and assume teamwork as an essential strategy for the success of any care practice.

BIOETHICAL COMPETENCES
For the present reflection, bioethics is understood as a discursive, deliberative and transdisciplinary subject, which aims to integrate biomedical, ecological, economic, anthropological, historical and philosophical knowledge in the systematic study of moral dimensions and behaviors of human beings around life.Moreover, it discusses ethical challenges we face today and will face in the future.The foregoing can be related to the approaches regarding the pattern of socio-political knowledge, such as the knowledge that encompasses other disciplinary knowledge, in a world in constant change.We can already identify convergences between the disciplinary bases of nursing, the deontological code of the CIE and bioethics, such as: the concern for equity in access and assistance to health systems, the protection of vulnerable individuals and communities, respect for autonomy in terms of decision making, in aspects related to the health of people and attention to environmental problems, among others.León and Arratia (7) affirm that in nursing professional practice the deontological elements of this subject require knowledge from the bioethical perspective.For the more clinical field of bioethics, these authors say nurses must contribute in the decision-making process from their knowledge about values expressed by the people in their care.In addition, they highlight the professional role of managing care, the obligation to participate in the defense of the rights of people regarding their health care and the pursuit of constant promotion, prevention and education in health (7) .Thus, nursing as any profession related to the field of health, requires choosing a perspective from the broad field of bioethics to guide the various professional practices and management, while maintaining their own moral heritage.Hence, it is important for nursing to establish an updated bioethical reflection that is abstracted from the biomedical analysis that contemporary bioethics has been dominating (8) .It becomes inevitable, then, that nurses will be introduced and trained in the deliberative method that constitutes the cornerstone for all bioethical reflection, since nurse professionals can contribute from their perspective and experience in clinical practice and interaction with people under their care to deliberate on various conflicts of values, which may arise.In this context, we must consider the contribution of professionals for deliberation, which can mean the participation of nurses in the care ethics committees, since they could know in greater detail the values and wills of people cared for and their families, as long as they have established a communication based on the principles of intersubjectivity with them.For such participation, it is essential that nurses in training acquire competences in analysis of bioethical problems, clinical situations and the application of deliberative methods.Considering the exposed aspects, bioethical competences can be defined as those by means of which nursing professionals and students identify, analyze and understand contemporary bioethical problems, are presented both in specific clinical situations, as well as in local, Latin American and global contexts, and participate by contributing from their disciplinary perspective in the identification, attention and solution of these problems through deliberation.

CIVIC ETHICAL COMPETENCES
Couceiro -Vidal (9) , understands bioethics as a civic ethic, applied to health care, in which the values on which civil life is based in Western democracies are integrated.Society demands, according to this author, the sanitary relation components of civic order related to the respect to the autonomy of citizens and the guarantee of access to the attention as a problematic of distributive justice, among others.This author emphasizes the need for medical schools to train professionals, required by society, and proposes to apply methodologies of reflection that include specific topics of the cultural, civic and social environment that would be experienced in practice.In addition to acquiring skills for deliberation in order to apply the rules of the democratic system to the clinical relationship.Nursing care is in civil life, and therefore must make civil values theirs as required by the deontological code of the nursing profession.Society demands professional training to promote civil ethical competences in its students, which could be defined as those that lead students to understand themselves as citizens, committed to the democratic society they participate in and possessors of notions of social responsibility with the problems and needs of it.In pursuit of the acquisition of these competences, it seems interesting to include in the respective curricula reflection and analysis around the deliberative possibility of collective "coconstruction" of civic values, such as: respect, freedom, dignity, solidarity, equality and inclusion.

DISCUSSION
Curricular updates oriented to competencies, considering curricular nursing plans have been affected, have led to the creation of training proposals, which involve the promotion of competences through transversal axes, as has happened with ethics.This entails important challenges for all the participating faculty (including professors who collaborate from practice assistance centers) in terms of cooperation, coordination and consistency of curricular activities, while demanding their training in areas of ethics and bioethics.According to the authors, it is of utmost importance that the axis of ethics is built on a theoretical basis clearly defined disciplinary ethics, when faced with these challenges (which are added to those of any moral education that is committed to promoting the moral agency of learners).This would make the formulation of achievable learning outcomes easier and their respective curricular activities.This process can be difficult if it is to implement ethics as a great generic competition, which could induce a rather generalist approach, or even vague and/or relativistic; but it could be facilitated by recognizing the different areas of the nursing ethos, as this article suggests.The three proposed competences, which are considered integrated and interdependent, can help to clarify the process, and contribute, at least in part, to overcoming the difficulty that could involve taking the ethical dimension into practice.They can contribute to the curricular activities of training plans, both pre and postgraduate, through a unified, systematic and collaborative work between professors, students and training institutions, implementing teaching strategies and learning that progressively supports the internalization of moral elements of this subject to the practices of learners.Ethical heritage is seen as an angular axis for the other ethical competences (bioethics and civics), to avoid an adoption of the biomedical bioethics, and to promote the empowerment of nursing in current bioethics (8) .Educational process must be concerned with personal development, especially moral, of its students.This is because health professionals seem to have, above all, the responsibility to constantly perform selfreflection; a recursive introspection that allows their own way of thinking, acting, of dialoguing and relating with others, which favors a continuous self-knowledge, and promotes the permanence of essential virtues, through personal and professionals habits (2)(3) .This process of constant introspection and self-reflection is called by Gallagher and Tschudin (10) as an internal ethical leadership, which could not be cultivated if no clear definitions regarding the ethical aspects to be formed in future professionals of Nursing are set.Thus, the definitions of the three proposed competences allow us to contemplate the aspects to be worked on during training and even during professional life.The integration of these will favor the development of a nursing practice of excellence, differentiating it from an exercise based only on the technical domain, which is not enough for human care purposes even generating a competent practice (4,6) .To progressively promote these three competences within the educational process, four essential pillars are proposed to guide the pedagogical strategies to be implemented.The focus is on personal development of each student, which would be the capacity for: intersubjectivity; introspection and self-knowledge; communication and dialogue; and critical analysis (2)(3)(4)6) .

Study Limitations
There is little literature that investigates and/or analyzes curricular experiences regarding the formative axes of nursing ethics, which makes the results (both difficulties and successes) of such training invisible.Studies should be conducted to show these results and thus allow curricular plans to evolve in favor of an ethical leadership in nursing.

Contributions to the nursing field
This study contributes to the nursing subject through the proposal to define three key ethical competences for the training of future nurses, so that they can be promoted contributing to the development of the internal ethical leadership of professionals.

FINAL CONSIDERATIONS
Given the intrinsic relation between personal development and the assumption of practices according to professional ethics by nursing students, the promotion of ethical competences through nursing training process is a complex task that requires constant and coherent cooperation, coordination and training of the teaching staff in charge.We expect that the definitions of three competences of the moral scope of nursing, contribute to cross-cutting proposals that promote the values and principles of the profession, visible in everyday practice.
Ethical competences for the development of nursing care Bratz JKA, Sandoval-Ramirez M.
Ethical competences for the development of nursing care Bratz JKA, Sandoval-Ramirez M.
Ethical competences for the development of nursing care Bratz JKA, Sandoval-Ramirez M.