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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.47 no.4 São Paulo Aug. 2013

http://dx.doi.org/10.1590/S0080-623420130000400023 

Original Article

Ethical problems experienced in a supervised curricular internship in nursing in an integrated curriculum

Juliane Cristina Burgatti1 

Luzmarina Aparecida Doretto Bracialli2 

Maria Amélia de Campos Oliveira3 

1Nurse. Doctorate in nursing, School of Nursing, Universidade de São Paulo (University of São Paulo). Assistant Manager in Teaching and Research, Hospital Servidor Público Municipal de São Paulo (Municipal Public Servant Hospital of São Paulo). São Paulo, SP, Brazil. juliburgatti@uol.com.br

2Nurse. Doctorate in Nursing, School of Nursing, Universidade de São Paulo. Professor of the Faculdade de Medicina de Marília (College of Medicine of Marília). Marília, SP, Brazil. luzbra@terra.com.

3Nurse. Doctorate in Nursing. Full Professor, Department of Community Health Nursing, School of Nursing, Universidade de São Paulo. São Paulo, SP, Brazil. macampos@usp.br

ABSTRACT

An exploratory, qualitative study with the objective of analyzing repercussions of the supervised curricular internship in the development of the ethical dimension of competency in undergraduate nursing students. Semistructured interviews were performed with 28 students, professors and nurse preceptors of a public institution of higher education in the state of São Paulo, during the period of October of 2010 to March of 2011. The empirical result was subjected to the technique of discourse analysis and resulted in the empirical categories: preservation of autonomy; social responsibility and respect in interpersonal relations in health care delivery and in the teaching – learning process; treatment and care from the ethical dimension; and, public responsibility and social justice. It was concluded that the phase that uses problematization as a method of teaching and learning provides critical reflection about professional practice in the services and system of health.

Key words: Education, nursing; Competency-based education; Professional competency; Ethics; Bioethics

INTRODUCTION

In professional health education, knowledge and skills are easily taught and acquired. More difficult is the development of attitudes guided by ethics. Moral behavior depends upon the maturity of the individual, and it is affected and influenced by reasons underlying behavior. Psychological maturity is a fundamental characteristic for humanization. People with psychological maturity are generally more open to learning, listening, recognition of their mistakes and the respect for differences. These attributes are not taught through theoretical lectures, but by contact with other human beings and the imitation of good qualities ( 1 ) .

Attitudes can also be taught through reflective practice, which includes four steps: detailing a situation; indicating the relevant virtues; determining the principles, and, ultimately, the variety of courses of acceptable action. This method also teaches the resolution of ethical problems, and promoting professionalism ( 2 ) . Students can also learn attitudes by observing professors and health professionals and the way they behave with patients, therefore, it is important to create opportunities to act in the actual environment of care ( 3 ) .

There are three educational models in bioethics: normative or deontological, pragmatic, and deliberative ( 4 ) . The normative or deontological model submits to the decision making based on standards and rules, while the principialist or pragmatic model is focused on the will of the subject alone, and does not consider fundamentals in the process of decision making. The deliberative model distances itself both from the measure by which the deliberation is made to the manner in which all involved in the situation participated as protagonists of the decision making process ( 4 ) .

In health education, the process of analysis and reflection should increase students’ understanding of complex problems, making them able to respond to them not only in technical terms, but also in terms of their own beliefs and values of the field. During professional education, students who are at different stages or in different levels of development of moral judgment, can progress to higher levels or stages, towards conscious ethical decision making, not influenced by norms and external determinations, but by values and ethical principles themselves.

In the health area, the teaching of bioethics is predominantly done in the discipline of deontology. However, the teaching of ethics permeates all disciplines in the transverse direction and needs based on the health contexts and processes of real jobs, establishing dialogues between students and professors ( 5 ) . The supervised curricular internship (SCI) is a modality of practical education that provides the transition from the academic world to the world of work, being a privileged space of contact with the reality of health care services and work. The awareness and understanding of ethical problems experienced in the SCI are fundamental for moral development and for prudent decision making in the health field.

This investigation aimed to identify situations experienced by students, professors and nurses of health institutions where the supervised curricular internship occured with nursing students in an integrated curriculum, oriented by competency.

METHOD

We conducted an exploratory study, with a qualitative approach, in a public, state-run Higher Education Institution (HEI) of São Paulo, located in the municipality of Marília, located in the midwestern region of São Paulo state, that offered an undergraduate nursing program.

The undergraduate nursing program, at the HEI being studied, adopted the integrated curriculum, oriented by competency. A part of learning includes real situations in the world of work, and the method of teaching – learning used was problematization, in order to enable reflection about real situations in professional nursing practice in the health services utilized as an internship site ( 6 ) .

The concept of competence adopted was depressed in constructivism and considered that it is in action that students’ performance is displayed, which mobilizes and constructs attributes for solving problems and health needs. The term competency is used in the singular, since it refers to professional practice and takes into account the integration between theory and practice, education and the world of work, recognizing culture and context, of values and ethics ( 6 ) .

In the fourth series of the nursing course, the part of learning in real situations of the working world had Professional Practice Units (PPU) as its setting: the Family Health Units and the Hospitals and Clinics I and II. It is expected that students in the fourth series develop three areas of competence: Health Surveillance; Care for Individual Needs in all phases of the life cycle; Care for Collective Needs, including in the area of Organization and Management of the Health Care Work Process ( 7 ) .

The pedagogical cycle of the PPU consists of the experiences and problematization of meaningful experiences of nursing students in actual practice scenarios. The lived experience of the student was shared with the group, that, identifying knowledge gaps, formulated learning issues and made a provisional synthesis. At the subsequent meeting, students reorganized the knowledge anchored in the the theoretical foundation, based on the scientific literature. The pedagogical cycle, based on the referential for competency, considers both the processes and the results in the teaching – learning process ( 8 ) . The SCI is conducted in the fourth series of the course, and corresponds to the PPU 4 ( 7 ) .

The study population consisted of: the coordinator of the fourth series of the course and other professors of the SCI responsible for the supervision of the curricular internship; students of the seventh and eighth semesters of the course; and, nurses of the health services the Municipal Secretary of Health of Marília who acted as preceptors for the SCI.

In dealing with a qualitative study, the sample size was not defined a priori, because what is fundamental is the participants themselves and if they will provide high quality information essential for the study. The saturation is linked indirectly to the object of the study, to the theoretical framework and of the completed editing. It depends, in a direct way, on the objectives, the population, and the degree of depth of the research ( 9 ) .

For the data collection, semi-structured interviews were conducted, supported with a script, in which the respondent was invited to relate a situation experienced in the SCI involving ethical issues. The empirical results from transcription of the recorded interviews was subjected to the technique of discourse analysis ( 10 ) . The texts were submitted to decomposition into themes and figures, and later composed empirical categories.

The study obtained approval of the Ethics in Research Committee of the HEI under protocol No. 450/10, and the interviews were conducted after receiving the free and informed consent form, with forms being signed by the participants.

RESULTS

Participant characteristics

We conducted 28 interviews; ten of these were nursing students in the seventh or eight semester, who participated in the SCI in the hospital units and in primary care. Ten professors of the undergraduate nursing course were also interviewed, and eight nurses of primary care or the hospital, who collaborated in the supervision of the SCI. These 18 interviews encompassed the entirety of the professors of the fourth series of the course and a large part of the nurse preceptors who collaborated in teaching the SCI. The statements of the respondents were identified by the letters E (students), D (professors) and P (nurse preceptors).

All of the nursing students interviewed were female, except for one, aged between 20 and 25 years, and maintained exclusive dedication to their studies, to which they devoted six to fifteen hours per week. The totality of the nurses interviewed were female, just as with the majority of professors, as only three were male. The age range of faculty interviewed ranged from 33 to 49 years, and the nurses were between 28 and 47 years.

A large part of the faculty worked in the higher education institution for over 19 years. As for postgraduates stricto or lato sensu , the majority reported having the title of doctor or were attending doctoral studies. Only two faculty reported having a master’s degree. With regard to the nurses, the time of work in the service was quite variable, ranging from eight months to 17 years. All were specialists, five of them in Family Health.

Empirical categories derived from the ethical problems experienced in the SCI

The discourse analyzed and its decomposition into figures and themes made it possible to identify four empirical categories as coming from the organization and the current health system, both related to ethical issues arising from the relationship between the professional teams with users and their families, and between professors and nursing students.

  • The preservation of autonomy and confidentiality of information and the privacy of the users of the health services;

  • The social responsibility and the respect of the intersubjective relationships in the production of health care and the teaching-learning process;

  • Treatment and care from the ethical dimension;

  • Public responsibility and social justice: universal access and comprehensiveness, the referral and counter-referral and the recognition of equity.

The most frequently mentioned problem was the lack of confidentiality of health information, associated with the principle or value of preservation of autonomy. The excerpt taken from the interview of a student revealed the issue of preservation of autonomy bound to confidentiality of information:

The patient who was hospitalized there, 17 years old, the patient is a crack cocaine user and entered with a suspected infarction. Then he went up to the ward and was admitted there. Only he told us that his family did not know he was a user and he asked that we not tell (...) So why not guide this boy to tell, to understand, to try to be open with his own mother... (E).

The ethical problems extrapolated from the interpersonal relationships extended to aspects related to the organization of the health system. The lack of material resources affected included interpersonal relationships, as in the case cited below:

A nursing assistant had not delivered the medication to a patient due to the fact of not having that role. The patient became angry and was swearing at her and ended up going after her. They were separated by a community agent... (E).

Aspects related to the teaching and student relationship raised several considerations, such as lack of commitment and honesty of the students, with cases of plagiarism in homework mentioned, and even falsification of the signature of a professor. Also cited was disrespect to the student, who sometimes felt exposed to the group of students during the internship:

A student who had difficulty with the preceptor to the SCI, had difficulty arranging meetings and this situation reached a point that we realized we would finish the course and he was unable to work with the SCI. This SCI suddenly appeared ready (...) which led us to think that the student had not done... (D).

In some of the cases reported, the argument of the respondents was based on the professional duty to do , in a reduction of deontological ethics, particularly in those aspects of the preservation of autonomy and the purely technical dimension of health work, such as in the testimony of this student, which illustrated the empirical category treatment and care from the ethical dimension:

In the stage of the hospital setting, one nursing assistant performed an inadequate procedure. In reality, in reading the medical prescription, she did not see one of the items that said that the drain was not to be removed from the patient and she pulled the drain without having ... that was not what was asked for on the prescription. But she assumed the responsibilities, saying, she explained that actually she had not read it, because the prescription had changed recently, it was the last item and she had not paid attention and had a punishment for that... (E).

The speeches also demonstrated ethical problems that are in the sphere of public responsibility and social justice, related to the principles and guidelines of the SUS, which whenn not experienced in the practice of health professionals, lose their meaning and significance.

One professor reported a situation of lack of access and comprehensive care for a pregnant woman at high risk due to excess demand on a unit due to an outbreak of dengue in the city. The excerpt below represented one of the major ethical issues in everyday health services, which are found in the empirical category, public responsibility and social justice, and were responsible for great tension in the professional activities:

She really had a coagulation disorder, she had several miscarriages throughout life, she had included a request for tubal ligation for this last birth. She was a person of 42 years, with a son who was much desired, a situation of a high-risk pregnancy. She was being followed in this high-risk ambulatory, and the team itself had failed to do this monitoring. We brought this up to discuss this situation with the team ... Because not even the resident ended up leading ... a situation that was a high-risk pregnancy and needed follow-up, even having difficulty with the staff, but as this team was going and would need to have a strategy to follow... (D).

DISCUSSION

The majority of ethical problems reported concerned the ethics applied to the micro context of the clinic. The most cited concerned confidentiality, which implied values of respect, solidarity and empathy, recognizing the patient as similar to oneself, gifted, therefore, by generic characteristics, derived in the human condition (possessing feelings and reasoning ability) and of others that may be particular (personality, opportunities and choices).

They also reported ethical problems of their own private sphere, such as autonomy, honesty, responsibility and respect. Some situations made reference to respect for patient autonomy, stressing that health professionals should stimulate him and assist him in developing the capacity for making autonomous decisions. For this it was necessary settle doubts and insecurity, as well as providing conditions such as information and different potential choices ( 11 ) .

Other situations coming from the clinical ethics reported by interviewees were the relationships themselves, permeated by the (lack of) responsibility and respect between the teams and the users and their families, but also among faculty and students. The disrespect among health professionals, users and their families was also described in a study about the perception of nurses and physicians about ethical problems encountered in primary care ( 12 ) .

The disrespect also occurred within the health teams, according to the perceptions of faculty, students and preceptors. This fact can be explained by the distance between the technical and ethical dimensions, which can accentuate tensions in daily work and internships in health, in particular the process of teamwork, which does not occur if the professionals work in isolation. It requires effort to coordinate actions and work processes of all professionals in search of consensus, which is only achieved by means of dialogue ( 13 ) .

A study on ethical problems occuring with nurses and physicians in primary health care also identified disrespect within the health teams. Such problems were generally derived from the very structure and power relations that shaped health practices ( 12 ) . In this study, the respect, or its lack, between professionals, users and families reached beyond the area of healthcare practices, also affecting relationships in academia.

Respect and solidarity are ethical attitudes that are strengthened in relation with one another, being constructed in daily life through a support network. In the training process, solidarity stimulates the feeling of belonging to the group within the subjects, which is fundamental for the feeling of freedom. But the group, by itself, does not guarantee solidarity ( 14 ) . It is worth questioning what is the faculty’s responsibility in professional training and how to create opportunities for the development of social responsibility within students.

The genuine reflexive, problematizing education allows students to approproximate reality. To stimulate creativity and problematization of reality is the major challenge of the professor. The more successful he is at this task, the more the comprehension of students will become critical and non-alienated. Critical thinking captures reality as a dynamic process, constantly in motion, as opposed to ingenuous thinking, in which time is static and standardized and the subject is accommodated in his beliefs ( 15 ) .

The actions of educational institutions need to be directed toward improving the social transformations and the health of the population, because the school should be a critical space that provides a holistic vision and dialectic of health problems ( 16 ) . Professors must approproximate reality with involvement, shared intentionality with other professors and interns, to critically analyze and question it, in the light of available theories.

The disrespect and lack of accountability and honesty in professional education were mentioned by professors. Students who copied work, as reported in the interviews, were not developing their skills and knowledge about a particular subject. Students who plagiarized work during education might even have been able to develop technical skills, but they lacked the knowledge to support the practice ( 17 ) .

It was not only situations involving ethical issues relating to the micro context that influenced healthcare work. The performance of students and nursing professionals also related to the ethics of the macro context, or public health ethics. In the routine health services, public health problems related to ethical issues were often present. However, there was still little awareness of such issues as ethical, because they were naturalized and incorporated into the routine of health care professionals, not being placed in evidence for students in the health area.

For example, material and human resources in unsatisfactory quantities and the precariousness of the organizational structures of work, together with asymmetrical relationships between the different professional categories, were problems that affected decision making and affected the quality of health work ( 18 ) .

It is known that the resources that the SUS provides to meet the needs of the population are insufficient, in flagrant contradiction with its structural principles, which include ensuring universal and equitable access to the Brazilian population ( 19 ) . The insufficiency of material resources and medications for the execution of healthcare work can generate ethical problems.

The Brazilian public health investments are low when compared to European countries or Japan, for example ( 20 ) . Therefore, the health discussions in Brazil should also cover public accountability, that is, the prioritization of public resources by the state, meeting the needs of those most in need, according to the principle of equity ( 21 ) .

Another challenge of the Brazilian health system, particularly at the municipal level, is completeness of the network of health services, since no level of attention has all the resources and expertise to meet the diverse demands for health. Primary care is the intersection point of service networks and health actions, which must organize care in order to facilitate its integration with other instances of access (longitudinality) and each continuous necessity or health problem ( 22 ) .

The guarantee for network access and effective responses to the needs of users enables the creation of a bonding relationship between them and health professionals, who must discern the common good and social justice. Thus, ethics focused on the individual context must be complemented by the ethics of the collective environment ( 16 ) .

Although the areas of the internships occur both in primary care and in hospital care, the ethical problems described by students, professors and health professionals were not caused by the use of high technologies nor were they restricted to purely a technical and biomedical view. These results may indicate that the use of active learning methodologies awakens critical reflections in the broad contexts for health, beyond the technical dimension.

CONCLUSION

In the initial and continuing formation of health care professionals, the critical understanding of the lived experience is essential. The teaching of ethics needs to enable the reflection on values, culture and decision making in a real context, favoring the moral development of students.

The integrated curriculum that uses problematization as a method provides opportunities for critical reflection on professional practice, the services and the health system, allowing the questioning of whether the legal and administrative rules respond ethically to the health problems of the population.

Ethical behavior is a consequence of the internalization of values and principles. Therefore, pluralistic and reflective ethics, based on the choice of internal values of respect, solidarity and justice, are not reduced by external determinations imposed by legislation, culture or even passing fads.

Nursing is a social practice and, as such, is related to the modes of production and reproduction of society. Therefore, in the initial education of future professionals, in addition to the technical dimension, the ethical dimension of professional competence should be emphasized, given their social responsibility.

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Received: July 16, 2012; Accepted: February 20, 2013

Correspondence addressed to : Juliane Cristina Burgatti. Escola de Enfermagem da USP. Av. Dr. Enéas de Carvalho Aguiar, 419 – Cerqueira Cesar. CEP 05403-000 - São Paulo, SP, Brazil

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