A training course on bioethics for Family Health Strategy professionals in

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 delibera ve bioethics, and aimed at presen ng the delibera on procedure as a means of handling ethical issues.

ics, and aimed at presen ng the delibera on procedure as a means of handling ethical issues. Contents were addressed in a crosssec on manner through fi ve sequen al acvity sessions at two diff erent moments of concentra on with one dispersion interval. In the fi rst moment of concentra on, key concepts and delibera ve bioethics contents were developed. The second involved delibera on sessions on moral confl icts, which were selected and prepared during the dispersion interval. Par cipants evaluated the delibera on as an appropriate instrument to deal with the ethical issues they are faced with. Problem-based learning was an eff ecve educa onal strategy for con nuing educa on in delibera ve bioethics.

Bioethics
Inservice Training Health personnel Primary Health Care

INTRODUCTION
Healthcare professions are dis nguished 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 recogni on of the moral plurality of the users and workers, the codes of professional ethics have been used insuffi ciently. Thus, it is necessary to incorporate the con nuous training of professionals for a new approach to ethics that fosters the acquisi on of delibera ve habits and considers the moral pluralism, the possibili es of the biotechnology and the transforma ons in the health and care. In the clinic, selfmanagement is imposed; the paternalis c benefi cence 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 rela onships of bond and feeling, i.e. the ethics of the rela onships. By including systema c training in knowledge, skills and a tudes, in a problema cal rather than manipula ve or indoctrina ng way, promo ng ethical competence, training in bioethics can provide professionals with a new way of cri cally approaching ethics in healthcare. Beyond being familiar with ethics, philosophy, legisla on and deontological codes, the professional must be competent to deliberate, responsibly and prudently. This requires ethical competence (1) .
Competence is the ability to act eff ecvely in diff erent professional situa ons, 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 cri cal and refl ec ve capacity of professionals, includes the ethical and poli cal areas (2) . The competent professional is able to judge, evaluate and consider problema c situa ons to fi nd alterna ve solu ons and decisions, also in the context of professional ethics. Ethical competence requires: knowledge of the ethical theories (to know); the ability to iden fy and resolve confl icts (to know how to do) and the true incorpora on of ethical values and principles into the professional a tude 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 con nuous 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 resolu on of ethical confl icts (3) . The educa onal process in bioethics aims for the development of prac cal skills and has the goal of developing skills to analyze and resolve ethi-cal confl icts autonomously and prudently, a er a deliberave process (5) . Although it is recognized that the development of skills depends on knowledge, this is not very useful for the improvement of the prac ces and rela onships in health, where the professionals know the history and founda on of bioethics perfectly, or even talk with ease about the ethical theories or the moral development phenomena, however are unable to iden fy and apply values and principles in the management of cases of confl ict. Therefore, prac cal skills must take precedence over knowledge. However, both are merely means and instruments for the main purpose of the forma ve process in bioethics: to problemaze the a tudinal aspects in order to transform the pracce towards ethical excellence (5) . Therefore, the greatest challenge in teaching bioethics concerns a tudes, because they relate to the autonomous choices of each regarding the type of professional they aspire to be (6) .
The objec ves of the training were: to provide knowledge of bioethics that enables the healthcare professionals to systema cally analyze and cri que the ethical aspects of their primary healthcare prac ce, considering the peculiaries 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 situa ons; to develop the necessary skills for moral delibera on in the face of ethical problems in primary healthcare, providing pruden al, refl ec ve, and considered judgments and allowing the arguments and counter arguments in a true dialogue of the team; to sensi ze the healthcare professionals to evaluate the ethical dimension of their prac ce in primary healthcare in order to recognize the ethical problems and the values in confl ict in these situa ons and put forward, in a responsible way, crea ve and sensible solu ons; to highlight the importance of the media ons necessary for delibera on in bioethics, such as therapeu c communica on, a helping rela onship, and empathic listening.

Approaches for teaching bioethics
Moral life is not merely a ma er of good will and correct inten on. It also requires arduous and pa ent learning as does any other human ability (6) . There are two approaches for the teaching of bioethics: pedagogic and Socra c. The fi rst is the most common. It is centered on the transfer of knowledge, focusing the teaching process from the elabora on, implementa on and evalua on of a program. The second approach, without neglec ng the rigor of the content, priori zes the transforma on of the being. This was what Socrates sought in dialogues with his disciples, hence the Socra c or maieu c approach. The teaching procedure of this approach is called maieu c, from the Greek maya (mother, midwife, the midwife's art) (5) . The Socra c maieu c 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, respec ully and pa ently assis ng the person in this process, as a midwife supports and accompanies the labor. The Socra c focus proposes to facilitate the interior transforma on of the a tudes (5) .
In primary healthcare, the pedagogic op on of problema za on can facilitate the opera onaliza on of the Socra c 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 cul va on of welcoming, bonding and caring a tudes and disposi ons. Problemaza on 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 crea ve solu ons. Thus, it is essen al to develop the ability to ask relevant ques ons so that, understanding the reality, the individual can iden fy and resolve confl icts, genera ng transforma ons in an autonomous and responsible way. Problema za on aims to develop the ability to observe the immediate surrounding reality as well as the global and structural reali es, in order to detect resources; to iden fy problems that hinder the effi cient and equitable use of these resources; and to fi nd ways of organizing the work and the collec ve ac on to achieve it (7) . By seeking to awaken the ability to ask relevant ques ons from sensi ve and accurate observa on and comprehension of the quo dian and structural reality, and to fi nd crea vely transforming solu ons, the Socra c approach and the problema zing op on are brought together as delibera ve bioethics teaching strategies. To deliberate is to ethically problema ze situa ons of moral confl ict, that is, the confl icts of values experienced in healthcare, to fi nd alterna ve courses of ac on, indicated as the op mal op on. It requires interpreta on of the real data, of the facts in their meaning connec ons; an analysis of life events, of the historical and cultural facts in their interconnec ons (8) . To deliberate well it is necessary to know how to problema ze the ethical context of the clinical cases. The Socra c approach must always exist in the teaching of bioethics. It is the an dote to indoctrina on, manipula on, imposi on, and also to the reduc on of the forma on to the mere transmission of informa on and moral instrucon, prac ces that generate frightened professionals, who do not know how to act in the face of ethical challenges and therefore seek protec on in the defensive prac ce (1) .
The problema zing teaching of bioethics allows each person to become the agent of their own transforma on and of the modifi ca ons in their care prac ce, enabling them to detect the ethical problems that arise from the quo dian reality, and seek original, crea ve, responsible and prudent solu ons. This type of teaching of bioethics requires: small, interac ve and par cipatory groups; approaches that are more prac cal than theore cal, including case discussions for the analysis of problema c situa ons of the quo dian ac vity in healthcare, not only of extreme and excep onal dilemmas that may be rare in the prac ce of primary healthcare professionals; discussion con nued through debates based on the knowledge learned and shared in the professional experience and in the biography of the par cipants. From the proposal of problema za on for the teaching of bioethics, we propose the model of delibera on as suitable for training in primary healthcare. Delibera on has the peculiarity of considering that the clinical situa on includes the various aspects that contribute to it, from ques ons relevant to comprehending the facts and iden fying the values in confl ict. It aims to trace possible solu ons and fi nd the op mal course of ac on, which is what prudently leads to the greater solidifi ca on of, or less damage to, the values in confl ict in the case. This ar cle reports the experience of implemen ng a training course in bioethics for nur ses and physicians from the Family Health Strategy in Santo André, São Paulo, based on problema zaon and delibera on, as the ethical theory and procedure for decision making.

The training in bioethics proposal
The training considered the peculiari es of the professional prac ce and the care in Family Health in Santo André (SP, Brazil). It used the problema zing approach as a strategy for the teaching-learning of delibera on in bioethics (8) , in order to develop and integrate a knowledge and skills base to deal with the ethical problems in healthcare. Delibera on is the process of self-educa on, almost self-analysis, which aims to bring about the transforma on of the professional prac ce with a tudinal changes. It allows one to interpret data and to establish connec ons of meaning in iden fying and addressing ethical confl icts. From the clinical situa on, the deliberave procedure provides the weigh ng and inclusion of the values and contextual factors that contribute to the situaon experienced by the user, their family and healthcare team. Thus, the comprehension of the life experiences is broadened, crea ng an environment conducive for the a tudinal changes of the professionals, with responsible commitment to the moral and technical excellence of their prac ce and care.
The educa onal proposal of the training was aimed at developing the skills and abili es necessary for moral delibera on. Included among these are: diff eren a on of the specifi city of bioethics, in rela on to the Law and professional deontology, when addressing ethical issues; sensi vity to perceive the confl icts of values in primary healthcare; integra on of the facts, values and du es in the founda ons of the decisions; implementa on of the steps of the delibera ve procedure to arrive at consistent decisions, from the contempla on of possible courses of ac on; improvement of the language for the clear descrip on of the ethical problems, of the confl ic ng values and of the courses of ac on; development of respec ul and dialogical coexistence with diff erent moral views. The training also aimed to awaken the professionals to the importance of knowing how to manage communica on and listening skills to be er deliberate on the ethical issues.
The training included fi ve sequences of ac vi es, in two moments of concentra on, interspersed by one of dispersion. Through theore cal-prac cal ac vi es, each sequence aimed to develop key concepts, skills and abilies essen al to train the professionals in the deliberave procedure. The ac vi es included group discussion about concepts, views and professional experiences; plenary sessions; case studies; applica on of the delibera ve method exercises; reading and discussion of texts; drama za on; class summaries; and wri en exercises. In the fi rst sequence, the key concepts of moral experience and ethical problem were worked with, aiming to discuss the diff erences between the concepts of ethical problem and ethical dilemma and to designate the moral experience, dis nguishing the contexts of facts, values and du es. The second had delibera ve bioethics as its key concept and aimed to present delibera on as knowledge of bioethics in the handling of ethical problems.
Moral delibera on, responsibility and prudence were the key concepts of the third sequence, which aimed to demonstrate how to opera onalize the delibera on procedure. For this, a hypothe cal case was used and the par cipants were urged to perceive that there are more than two possible alterna ves for solving ethical problems. With this, it was hoped to go beyond the extreme for and against views and to fi nd intermediate solu on 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 peculiaries of the professional-user rela onship in primary healthcare. The last sequence focused on the ethical issues in the rela onships of the team, no ng the importance of resolving the moral confl icts in a reasoned way through means of asser ve communica on. Based on the key concepts, during the sequence of ac vi es contents were addressed, such as: genesis, history, concepts and scope of bioethics; commonali es and specifi ci es of moral languages, ethics, professional ethics, law and bioethics; the ethical and moral experiences, with the levels of the values and du es; moments of analysis of the moral act; the fallacies about bioethics; the virtue of prudence; moral responsibility in clinical prac ce; the peculiari es of bioethics in Primary Healthcare and Family Health. The fi rst moment of concentra on was followed by two weeks of dispersion, during which par cipants had to choose an ethical problem that they had experienced in their prac ce in primary healthcare and to prepare it for the ses-sions of delibera on that would be developed in the second moment of concentra on. The total workload was 40 hours, with 30 hours dedicated to concentra on ac vi es: 20 hours for the sequences of ac vi es and 10 hours for the sessions of delibera on.
To evaluate whether the objec ves of the training had been achieved, the par cipa on and involvement of the par cipants in the ac vi es, the performance in the written exercises, and the presenta on of the case for delibera on, were used. In order to es mate the mobiliza on of the sensi vity for the percep on of ethical problems, an instrument for inventorying this type of situa on in primary healthcare was applied before and a er the training. For the overall evalua on of the training the par cipants were asked (06 physicians, 06 nurses and 01 den st): What have you learned during the delibera on sessions of the course? How will the course infl uence your daily work prac ce?

The evalua on of the proposal
The professional par cipants reported that the course le them more confi dent to deal with situa ons of moral confl ict, because they comprehended the need to analyze problems and situa ons from diff erent points in order to visualize the various alterna ve courses of ac on 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 situa on, with it being necessary to analyze each case without prejudgment. They recognized that the exercise of applica on of the delibera ve procedure contributed to them appropria ng knowledge that would allow them to reach consistent decisions and debate the moral point of view. Regarding the course structure, the evalua ons indicated the need to increase the workload of the second moment of concentra on so that everyone can present their cases.

DISCUSSION
Learning ethics begins by imita on: Pedagogy of the example, hidden curriculum (1) . If we consider that the basic health units are fi elds for the prac ce of the students, the con nuous training in bioethics of the family health teams can have repercussions in the ini al training of the future genera ons of professionals. The ethical, ini al and connuous training of healthcare professionals is essen al for excellence in care. This includes technical and scien fi c 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 unsa sfactory quality. Indeed, the clinic loses quality if the interpersonal plane is ignored. The rela onship between the professionals and users is not merely a bureaucra c or administra ve proceeding, but the bond, the interpersonal encounter for the care. Therefore, ethical responsibility and commitment has to be incorporated into a dialogical clinical rela onship that provides an exchange of values, feelings and beliefs, as well as the communica on of signs, symptoms and examina on data (9) .
The teaching of bioethics implies openness to dialogue, as the condi on and result of the educa onal 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 cri cal and prudent evalua on concerning that which should be encouraged and that which seems inadvisable or intolerable for the present and future health of the popula ons, the Earth, or even for the dignity of the people (10) . The teaching-learning of bioethics aims to prepare professionals for this dialogical consulta on within the context of their clinical prac ce and teamwork (8,11) .
To recognize the dialogical validity of the diff erent posi ons and arguments drawn from diff erent systems of moral thought does not mean being neutral. The training in values has usually been performed with two antagonis c trends: the imposed, which takes the values as something objec ve to be assumed by the individual, even at the expense of imposi on, and the neutral, which considers the values as subjec ve en es about which ra onal argument is not worthwhile. Between imposi on and neutrality, lies the delibera ve model (12) the object of the teaching experience reported. Delibera ve habits require the media on of means and instruments from other areas of knowledge, such as clinical interviewing techniques, emo onal support, therapeu c communica on, and a helping rela onship (9) .

CONCLUSION
Problema za on was shown to be eff ec ve as an educa onal strategy for teaching-learning in the con nuous training of the professional in delibera ve 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 posi ve evalua ons of the par cipants, 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 me for the prac cal applica on of the procedure of delibera on and to provide prospec ve follow-up mee ngs.