Active methodology in continuing education to address ethics and bioethics

Abstract

This qualitative research, based on the discourse of the collective subject, analyzes distance education as an active methodology in the continuing education of a nursing team at a university hospital in Minas Gerais. Data were collected by means of a questionnaire and a focus group, and organized according to three central ideas that emerged in the meetings. Research participants see distance education as an active teaching methodology that enables interventions at work, provided that there is necessary infrastructure for developing the work process and implementing training in the work environment. The analysis also emphasizes the importance of nursing workers being an active subject in their teaching-learning process, using continuing health education to provide integral, ethical, and safe care to the Unified Health System users.

Education, distance; Education, continuing; Unified Health System; Professional training; Nursing

Resumo

Mediante pesquisa qualitativa com a técnica do discurso do sujeito coletivo, este estudo analisa a educação à distância como metodologia ativa na educação permanente de equipe de enfermagem de hospital universitário de Minas Gerais. Coletados por meio de questionário e de grupo focal, os dados foram organizados conforme três ideias centrais que emergiram nas reuniões. Para os participantes da pesquisa, a modalidade à distância pode ser considerada uma metodologia ativa de ensino que possibilita intervenções no trabalho, desde que haja infraestrutura necessária para o desenvolvimento do processo de trabalho e realização das capacitações no ambiente laboral. Para concluir, ressalta-se a importância do trabalhador da enfermagem ser sujeito ativo do seu processo de ensino-aprendizagem, utilizando a educação permanente em saúde para prestar assistência aos usuários do Sistema Único de Saúde de forma integral, ética e segura.

Educação à distância; Educação continuada; Sistema Único de Saúde; Capacitação profissional; Enfermagem

Resumen

Desde una investigación cualitativa con la técnica del discurso del sujeto colectivo, este estudio analiza la educación a distancia como metodología activa en la formación permanente del equipo de enfermería de un hospital universitario de Minas Gerais (Brasil). Se recopilaron los datos mediante un cuestionario y un grupo focal para organizarlos de acuerdo con tres ejes centrales que surgieron en las reuniones. Para los participantes de la investigación, la modalidad a distancia puede ser una metodología de enseñanza activa que posibilita intervenciones en el trabajo, siempre que exista la infraestructura necesaria para el desarrollo del proceso de trabajo y la realización de capacitaciones en el ambiente laboral. Es importante que el profesional enfermero sea un sujeto activo en su proceso de enseñanza-aprendizaje al usar la educación permanente en salud para brindar asistencia integral, ética y segura a los usuarios del Sistema Único de Salud.

Educación a distancia; Educación continua; Sistema Único de Salud; Capacitación profesional; Enfermería

Professional education has been the subject of several debates in the field of health, tackling the formats and modalities of pedagogical activities, especially professionals’ motivations for seeking individual training and the initiatives offered by services. In this perspective, continuing health education programs (EPS) must meet the social health care needs advocated by the Unified Health System (SUS), besides ensuring a comprehensive, humanized and quality care ¹.

Officially institutionalized in 2004, the National Policy for Continuing Health Education (PNEPS) incorporates contextualized teaching and learning into the daily life of organizations and social and labor practices. Moreover, it substantially modifies educational strategies, allowing students to be actors who reflect on the practice and produce knowledge and action alternatives ².

From a theoretical and methodological standpoint, the PNEPS proposal follows a dialectical perspective and chooses problematization as a teaching methodology, as well as cross-sectional discussions among subjects, considering work situations valuable educational resources. Such an approach involves reworking the acquired knowledge, adapting it to one’s work reality; it also values dialogue and discussion within teams, as forms of recognizing differences that pose obstacles to organizational changes ³.

In this context, distance education (DE), due to its logic of facilitation and mediation, meets the EPS proposal, since it shifts the focus away from the teacher, who goes from holder of knowledge to mediator of learning, towards a student-centered pedagogy ³. Such paradigm shift presupposes critical individuals who actively engage in the teaching-learning process by critically positioning themselves before situations and problems presented in the virtual learning environment (VLE), aided by technological resources ⁴.

The rise of digital information and communication technologies has expanded the offer of distance education programs, especially those available in different digital media. While these educational resources are mostly used by higher education institutions in virtual learning environments ⁵, few studies have reflected on the use of distance education as an active methodology in EPS.

For this purpose, we sought to examine the active methodologies based on Freirean pedagogy, whose principles advocate a student-centered learning process, the teacher as a facilitator, the autonomy of the subject, the problematization and reflection of reality, and collective work ⁶.

Active methodologies oppose the traditional teaching method, understanding students as historical subjects. Instead of passive individuals, simple knowledge repositories, they need to be valued as knowledge producers with valuable experiences, knowledge, and opinions ⁶.

In a scenario of emerging new distance education experiences, the need for reflections on the use of DE in health continuing education, especially in nursing, increases. Continuously proposing educational actions for these professionals is of paramount importance to promote personal development and to offer safe and humanized health care.

For this study, we elaborated the following research question: can distance education, as a modality of offer and an active methodology used in EPS, provide a reflective learning based on the reality of everyday work? To answer this question, we offered a distance course on ethics and bioethics to nursing professionals who participated in the Nursing Ethics Commission (CEE) of a university hospital located in the state of Minas Gerais, Brazil.

Offered on the Moodle platform, the course lasted 12 weeks and consisted of four units, whose contents aimed to examine ethical, bioethical, and legal aspects of everyday health care work, especially in nursing.

Through the debates and reflections promoted, the nursing professionals were encouraged to improve their ability to act with scientific competence and sense of responsibility to, based on ethical principles, promote the integral health of users. For this purpose, we developed a study guide written in dialogical language and containing didactic sequences, which allowed participants to actively and critically expand their reflexive capacity regarding their professional performance and the topics of ethics and bioethics.

For the present study, we outlined the following objective: to analyze distance education as an active methodology used in a continuing education course offered to the nursing team of a university hospital in Minas Gerais, Brazil.

Method

To analyze the use of distance education as an active methodology for training nursing professionals, we conducted a qualitative research based on the discourse of the collective subject (DCS) approach ⁷, structured by the following concepts:

• Key expressions (KE): verbal material excerpts selected from the statements that best describe their content and units of meaning;

• Central ideas (CI): equivalent of categories, they have the role of identifying, naming, and distinguishing one position from another; they are synthetic formulas, units of meanings that describe the senses present in the individual statements and in the set of statements of different individuals that present a similar or complementary sense;

• Discourse of the collective subject (DCS): gathering of the KE present in different statements that have CI with similar or complementary meaning.

Thus, the DCS methodology seeks to describe and express perspectives on a proposed topic in a given sociocultural context ⁷. In our study, DSC contributed to search for meanings shared by nursing professionals related to the distance education modality used in EPS.

Conducted in a general university hospital located in the state of Minas Gerais, with 547 beds and accredited to exclusively serve SUS users, the study involved nine nursing professionals, members of the Nursing Ethics Commission (CEE), who agreed to participate in the research after signing an informed consent form.

Inclusion criteria consisted of being a CEE member and attending the distance education course on ethics and bioethics. Professionals who were on vacation or on leave and professionals who agreed to participate but did not complete the course were excluded.

Data were collected by means of a questionnaire applied shortly after the course ended, with questions about the professional’s profile and the objectives, content, teaching strategy, and educational material used, seeking to apprehend the participants’ perceptions regarding the teaching methodology used. These answers were used as guidelines in a focus group conducted in April 2018 with five of the nine nursing professionals who completed the course. This allowed for a more in-depth analysis of some aspects of the active methodology employed.

Focus group is a qualitative research technique, which takes the form of a group interview, appropriate for when the research objective is to verify how people evaluate an experience, idea, or event ⁸. In this phase of data collection, the answers were recorded and later transcribed.

The focus group data were then organized into panels of discursive statements, an important instrument for constructing the DCS, which, in turn, allowed us to visualize the relations between the studied phenomena, supporting the interpretation and communication of findings.

Subsequently, we began the data analysis by defining general thematic categories (GC) that reflected the research objectives:

• Meanings of the distance education course on Ethics and Bioethics in Nursing;

• Relevance of the course content to the work context;

• Tools used in the course;

• Adequacy of the course to the EPS actions for nursing professionals.

These categories, elaborated from the participants’ statements, were redefined during the analysis.

Results

Of the nine professionals who completed the course, five answered the questionnaire. The group’s mean age was 43.2 years old; 80% are female; 60% are nurses, followed by nursing technicians and assistants; 40% work in the adult ICU and the remaining in inpatient units; 80% hold leadership positions; 80% work in day shifts. On average, individuals have 15.8 years of training; 60% have 3 years or less of service at the institution; 80% work at another institution; all participants have tertiary education; and 80% have a specialization. The mid-level providers (nursing technicians and assistants) who participated in the data collection also had a bachelor’s degree.

These same five professionals participated in a focus group structured by the DCS approach, a technique that explicitly proposes a descriptive reconstruction of opinions or meanings attributed by collectivities or social groups to certain events.

The DCS allowed to overcome a formal presentation of the results, since the statements were analyzed as collective discourse, enabling the emergence of collective thought during descriptive reconstruction as direct speech—that is, without theoretical intermediation. At the collective scale, the discursive nature of thought and its autonomy as an empirical fact are thus preserved, which allows safeguarding the spontaneity and naturalness of collective thought ⁷.

Three central ideas (CI) emerged from the participants’ statements, whose key expressions (KE) allowed to construct collective discourses regarding the participants’ identification with the topic of ethics, distance education in health education programs (EPS), and institutional support for continuing education.

Central idea of the first discourse of collective subject

As illustrated by the discursive excerpts below, the KEs pointed to a “strong identification of the participants with the topic of ethics,” which was fundamental in their decision to take part in the distance education course on Ethics and Bioethics in Nursing.

“Ethics is a topic that I like and relates to our everyday experiences in life, in our country. I think it helps us to reflect on our society, not only regarding work, but it also opens up other perspectives.”

“I loved it, because this topic is present not only in our professional life, but in everything, our personal lives, family, neighbors, even during commuting, we are ever-connected to this issue of ethics.”

“Talking about ethics is not simple. After this course I understand that ethics is not a ready-made concept; it depends on the person’s experience, their context, ethics and morals. But I see that the concepts of morality and ethics get mixed up a lot, you know? We try to separate them, but at the same time we realize that the two go together. You can’t just say ‘That’s ethical, that’s not ethical’ because it depends on other things. So today, I think ten times now before saying ‘Oh, that’s unethical’.”

“Because I think that talking about ethics, bioethics, morality, which is something built in society, is very important. I honestly liked it, it’s a topic that I like. It made learning much easier.”

Central idea of the second discourse of collective subject

The second central idea, defined based on the statements of nursing professionals about the course taught at EPS, refers to KEs showing that it “being offered in the distance education modality was decisive for the participation of nursing professionals, providing reflections on professional practice and further discussing the topic”:

“The DE methodology used was great. It’s like my colleagues said, the question of how we organize ourselves to participate. I myself did the activities at night, when everyone was already asleep. I logged onto the platform and concentrated on the lessons. Sometimes I didn’t even spend that much time. This a topic that requires great concentration to follow the reasoning, you can’t just read in a superficial way, you start reading in depth. So, the topic and the methodology were very valid, and I intend to continue putting this into practice.”

“I like the distance education method, because it allows you to adjust the lessons to your day. So, sometimes I studied in the afternoon, when my sons were at school; other times I studied at night, when I wanted to see the video, for example, because then it had less noise, everyone was already asleep; I studied on my days off, the weekend. You find the best time for you, is what I realized.”

“I really like distance education, it’s a very good tool that we have to use. One experience I had during the course: I was on vacation in Fortaleza, at Praia do Futuro, and could easily access the videos, can you believe that? At Praia do Futuro! Then I met someone and started talking about ethics.”

“It’s a method that facilitates access, a tool that you can access anywhere. I accessed it in the morning, afternoon, or at night, whenever I was available.”

Central idea of the third discourse of collective subject

Another issue often raised in the discursive statements concerns the work context. The KEs highlight the central idea of a lack in institutional support and recognition for developing and participating in continuing education activities:

“I like distance education, but ideally we should be able to do everything within working hours.”

“During working hours it’s impossible. First of all, the demand for service is great, even in quieter days. Second, we have only two computers per sector. Besides, nurses have to share it with the doctor... with everyone. Got it?”

“It’s very complicated to access anything during working hours, even by smartphone, because management disapproves of using cellphones during work.”

“And we don’t have wi-fi, not everyone in the hospital has internet access. So, during working hours it’s very complicated.”

“I’ve taken several distance education courses and it’s commitment in your schedule, but it has to be compatible with the person’s actual availability, you know.”

“If they really wanted nursing to develop, they would have open wi-fi in a teaching hospital. Why can’t we have open wi-fi to everyone inside the hospital? They can keep blocking improper websites but leave the wi-fi open for research. If suddenly a patient arrives with a different disease, you don’t have a computer for research, or you can’t access the computer, because they will accuse you of messing around during work.”

“You have your smartphone, you could quickly search something, but it depends on having internet access. Why can’t a teaching hospital have open internet to everyone? Why is there easy internet access only in the director’s office? Or in the coordination?”

“I see it as a way to hinder nursing work, that is, the nursing team does not deserve it. Nurses don’t need to learn, they’re here to provide assistance, why do they need a computer for?”

Importantly, the categories found relate to political-managerial and financial aspects of the PNEPS management and planning process, as well as to conceptual and methodological aspects involved in preparing and executing EPS actions.

To operationalize EPS actions, we must use a methodology appropriate to the topic to be explored, the work situation to be analyzed, and the expected objective. For research participants, distance education can function as an active methodology, that is, capable of intervening and prompting behavior changes in the work environment—provided that participants have the necessary space and infrastructure to work and dedicate themselves to educational programs.

Discussion

Engagement, a concept proposed by Sartre, brought a sense of ethical commitment to the reflection regarding the “identification of participants with the topic of ethics.” Ethical engagement (or individual commitment in the choice process) implies the choice and beginning of a project that initially seeks the individual’s personal development ⁹. As Paulo Freire wrote, one’s ethical development is based on individual freedoms and an awareness of being in the world—a historical awareness elaborated by practices of authentic and qualified dialogue, which lead to personal growth and, consequently, amplify the potential for transforming their surrounding reality ¹⁰.

Ethics is inseparable from practical activity; but individual choices alone are not enough to develop and ensure the ethical behavior of health professionals. One must consider teaching methods and strategies, and conflicting contexts of coexistence at work should act as the background for ethical reflection and learning. Real and direct experiences of collective life and health care work are the contexts in which ethics teaching and learning take place most effectively. Having an environment in which ethics and its practice are a reality is thus fundamental ¹¹.

Distance education undoubtedly contributes to the transformation of teaching methods and work organizations in conventional systems, as well as to the proper use of technologies for mediating education. Information and communication technologies, when used in distance education in conjunction with a variety of media, can expand the geographical scope of professional and human development actions at a low cost. Thus, this teaching modality facilitates learning in the institution itself, without taking professionals away from their activities for long ¹².

As a recognized and effective education model that increases the reach, quality, and access to learning, distance education is a way of democratizing knowledge. Health professional must strive to include this facilitating teaching method permanently in institutions, understanding that this form of teaching meets the demands of our contemporary world, in which the use of various means of knowledge production allows one to choose how, when, and where to learn ¹¹.

Integrating and adapting distance education to the work environment still faces several challenges. Besides the lacking supply of human and material resources, we highlight the difficulty some professionals have in accessing and using information and communication technologies; shortage of time to develop the course activities, due to double employment; communication difficulties with tutors, due to living in very distant places; the family life routine, among others ¹¹.

Nursing work, especially that of nurses, is weakened in relation to institutional human resources policies, cultural changes, and the labor market. Institutional physical, organizational, and service maintenance conditions were also pointed out as contributing factors to the low effectiveness and/or small impact of training actions proposed.

Professionals admit to difficulties in putting into practice what is learned and point to administrative issues as factors that interfere with performing actions. We arrive at an impasse: training is conducted, but no actual conditions are created to implement the changes proposed by educational actions and in accordance with their guiding principles ¹³.

Regarding infrastructure and institutional support for EPS activities, a recent document issued by the Ministry of Health’s Work Management Secretariat highlights that the PNEPS has promoted advances in health education. However, the document calls for increased efforts to articulate institutional partnerships between service and teaching, education and work, in a dialogical and shared perspective ¹⁴.

The goal is to strengthen EPS as a guideline for new practices that guide reflection on the work process and the elaboration of collaborative and meaningful learning activities, favoring teamwork, participatory management, and co-responsibility in teaching-learning processes, to achieve SUS’s strategic objectives ¹⁴.

This analysis of the PNEPS implementation in states and municipalities points to important evidence on the advances and difficulties faced in the process. Among the difficulties, we mention the little coordination between managers, workers, social control, and higher education institutions; the reduced implementation of regional permanent committees for service-learning integration; the incipient participation of municipal managers; the lack of defined parameters for project building; the absence of evaluation of the projects developed regarding their desired changes in training, management, and health care practices; and the difficulties in using financial resources ¹⁴.

Incorporating active methodologies in the nursing work process contributes to the professional training process by meeting the organization requirements to exercise this profession. The use of these methodologies allows professionals to take a critical and reflective position in the construction of their own learning ¹⁵.

By considering distance education an active and appropriate methodology to unveil the potential that media and digital platforms represent for EPS, this study corroborates the reflections of a theoretical essay on some of the advantages regarding its adoption: visibility and dissemination of EPS actions across the Brazilian territory; replication and readaptation according to local needs; use of existing tools to operationalize, monitor, and evaluate the actions, with lower cost to the health system; and others ¹⁶.

Using active methodologies in EPS allows for reflective learning of professional practice, considering the reality of health services—because active methodologies are teaching strategies that have problematization as their axis. This strengthens the technical, social, and ethical aspects related to health professional edcuation.

Final considerations

The nursing professionals who participated in the distance education course on Ethics and Bioethics in Nursing can be considered to be ethically engaged professionals because, besides identifying with the topic, they sought personal growth and, consequently, expanded their potential to transform reality. This suggests that this active methodology allows a problem-based reflective learning anchored on the work process.

Moreover, offering the course as a distance education program was crucial for their participation in the proposed activity. We noted, however, that challenges remain for widespread participation—even when offered in this modality—due to working conditions, infrastructure, and lack of institutional support.

The reduced number of nursing professionals in the course offered—one of the limitations of this study—may be explained by work overload, absenteeism, and the extensive course load, which was considered in the staff dimensioning and working hours. Further research is needed to broaden the understanding of active methodologies in the training process of healthcare providers.

Despite its limitations, this study can contribute to technical-scientific production on EPS, active methodologies, ethics, and bioethics. Thus, besides strengthening the PNEPS, it presents a teaching strategy that favors problematizing the reality of services and a critical and reflective teaching-learning process. The need for and importance of defining institutional policy guidelines that favor the effective participation of nursing professionals in continuing education actions at the university hospital is without question.

In conclusion, we highlight the importance of seeing nursing professionals as active subjects in their teaching-learning process. EPS must show its relevance as a tool to increasingly qualify the comprehensive, ethical, and safe care provided to SUS users.

Agradecimentos

We thank the Minas Gerais Research Foundation (Fapemig) for funding this study by means of a scholarship for undergraduate research through Notice 1/2016 of the Pro-Rectory of Research of the Federal University of Minas Gerais.

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• Approval CEP-CAAE 46290215.9.0000.5149

Publication Dates

• Publication in this collection
  20 Feb 2023
• Date of issue
  Oct-Dec 2022

History

• Received
  4 Jan 2022
• Reviewed
  5 Oct 2022
• Accepted
  7 Nov 2022