Educating for bioethics: a challenge in nursing

Abstract

Educating for bioethics is a challenge today. This challenge is even greater when we think of the teaching of bioethics to nursing students, who will perform a profession that has as its maximum target the care of other people. Because it is a profession that implies the relationship with the other and the provision of humanized and appropriate care to each situation, it is important to develop teaching tools that promote not only technical improvement and knowledge of how to do a task, but also the development of moral, personal and professional skills that lead to excellent health care. This article presents a reflection on the teaching of bioethics and its relationship with the development of moral competence of nursing students, suggesting some strategies that enhance the teaching of bioethics and the education of increasingly competent nurses.

Keywords:
Moral development; Bioethics; Teaching; Students, nursing; Professional competence

Resumo

Educar para a bioética é um desafio na atualidade. Ainda maior se torna este desafio, quando pensamos no ensino da bioética a estudantes de enfermagem, que irão desempenhar uma profissão que tem como expoente máximo o cuidar da outra pessoa. Tratando-se de uma profissão que implica a relação com o outro e a prestação de cuidados humanizados e adequados a cada situação específica, torna-se importante desenvolver ferramentas de ensino que promovam não só o desenvolvimento técnico e o conhecimento de como fazer, mas essencialmente o desenvolvimento de competências morais, pessoais e profissionais que conduzam a cuidados de saúde de excelência. Este artigo pretende apresentar uma reflexão sobre o ensino da bioética e a sua relação com o desenvolvimento da competência moral dos estudantes de enfermagem, assim como sugerir algumas estratégias no ensino da Bioética que potenciem a formação de enfermeiros cada vez mais competentes.

Palavras-chave:
Desenvolvimento moral; Bioética; Ensino; Estudantes de enfermagem; Competência profissional

Resumen

Educar en bioética es un desafío en la actualidad. Esto se vuelve más grande cuando pensamos en la enseñanza de bioética a estudiantes de enfermería, quienes desempeñarán una profesión que tiene la máxima expresión la asistencia a las personas. Por ser una profesión que involucra la relación con el otro y la prestación de una asistencia humanizada y adecuada a cada situación específica, es importante desarrollar herramientas didácticas que promuevan no solo el desarrollo técnico y el conocimiento de cómo hacerlo, sino fundamentalmente el desarrollo de competencias morales, personales y profesionales que promuevan una excelente atención en salud. Este artículo reflexiona sobre la enseñanza de la bioética y su relación con el desarrollo de la competencia moral de los estudiantes de enfermería, así como sugiere algunas estrategias para la enseñanza de la Bioética que promueva una formación de profesionales cada vez más competentes.

Palabras clave:
Desarrollo moral; Bioética; Enseñanza; Estudiantes de enfermería; Competencia profesional

We live in an age in which advances in health care emerge continuously, something that generates numerous ethical dilemmas. Associated with this, there is a greater difficulty regarding nursing students making decisions and acting accordingly. This ability, also called moral competence, should be essential to nurses, given the importance of encouraging the development of moral and professional competencies of nursing students since their initial education.

Teaching bioethics by promoting diverse ethical dilemmas debates of nowadays seems to us to have a relevant role in the improvement of nursing students’ moral competence. That is why we decided to make a study on this subject by analyzing the current state of the art regarding the relationship between teaching bioethics and the nursing student's moral competence.

Literature on this subject and the possible relationship that may exist between teaching bioethics and the development of moral competence is still scarce. Some authors found a moral competence stagnation in nursing students ¹–³ or even its decrease after graduation ⁴. This leads to a reflection on what can be done to counter this trend, to develop a critical-reflective thinking and decision-making ability in nursing students.

Moral and professional competence

Competence is understood as habitual and judicious use of communication, knowledge, technical skills, clinical judgment, emotions, values, and reflections in daily practice to benefit both the individual and the community ⁵. According to the International Council of Nurses (ICN), competence is a defining characteristic of a nurse. And a competent nurse must have knowledge, understanding, and critical judgment ⁶. Nurses must also demonstrate solid cognitive, technical, and interpersonal skills, in addition to a range of appropriate personal attributes and attitudes ⁶.

Benner defines competence as an area of skilled performance identified and described by its intent, function and meanings ⁷. The author presents the nurses’ competencies development model entitled “the novice to expert model,” which comprises several steps that describe and interpret the skills development and clinical judgment in nursing practice ⁷,⁸. Clinical expertise is the last stage and is achieved when theoretical and practical knowledge merge and when the experienced nurse develops the ability to make appropriate decisions, even in complex situations.

In this phase, nurses should have a complete understanding on how to best interact with their patients, along with combining intuition and theoretical and practical knowledge to provide excellent nursing care ⁷,⁸. We thus speak of a professional competence for nursing practice of a more technical nature, since the experience of interacting with patients in the clinical environment contributes directly to its improvement.

Moral competence usually relates with theories about moral judgment development, which is considered a psychological capacity necessary for decision-making, and can be understood as the ability to solve problems and conflicts based on a moral principle, through deliberation and discussion rather than the use of force, power or violence ⁹. In this case, moral competence is the ability to evaluate various situations and respond according to moral principles learned throughout life.

However, different approaches exist on this topic, and some authors argue that individuals develop their moral and professional skills in parallel throughout nursing education ¹⁰. Other authors emphasize the importance of developing specific moral competencies for nursing, such as moral competence in mediating stressful situations and promoting hope, even in difficulty situations ¹¹. Furthermore, the ability to teach and accompany students is pointed out as a challenge experienced by professors when trying to develop nurses’ moral competence in clinical practice ¹².

Another definition, specifically from nursing moral competence, combines professional with moral competence, which is considered as the ability of a nurse to use professional nursing values, ethics principles and nursing standards in a favorable work environment to think critically, make ethical or moral decisions and solve problems in the provision of quality and ethical care, meeting the needs and satisfaction of patients in nursing practice ¹³.

A reflection on the concept of morality is necessary to understand these definitions. The word “moral” derives from Latin moralis, which means “relating to customs.” It relates to the rules that determine what is right or wrong in the conduct of human beings according to the society in which they live and covers rules of conduct related to moral principles, rights, rules, and virtues ¹⁴,¹⁵. Early in life, all members of a given community learn the responsibilities and moral rules that they are submitted and which they are expected to fulfill. However, certain norms and rules refer to specific groups (that is, professional categories) and are governed by rules of conduct that often take the form of deontological codes, as in the case of professional morality ¹⁴. In the case of nurses, it implies that they act according to the norms and principles developed during their education, allowing them to provide excellence care appropriate to each patient.

Therefore, we understand that this morality must be related to professional competence and cannot be dissociated from it since both evolve in parallel throughout nurses’ education. Moral competence is what determines how nurses work in each specific situation; however, this performance also depends on what was previously learned and developed during clinical practice. Professional morality can shape moral competence, but the internal principles inherent to each individual will affect their choices and actions and their conduct toward controversial issues—which professional groups may accept (professional morality), such as abortion or euthanasia. Moreover, nurses should neither accept nor practice such acts if they harm their moral integrity.

Considering that ethics studies the reasons towards the actions, we believe teaching bioethics plays a relevant role on the development of moral competence of nursing students.

Teaching bioethics: strategies to promote moral competence

We believe that some measures in teaching bioethics to nursing students may play an extremely relevant role, therefore we present and discuss strategies to implement or deepen its teaching.

Promoting bioethics teaching to other levels

Previously, a family consisted of several people living in the same house and maintaining a direct and permanent relationship with siblings of different ages or grandparents, who at some point could be debilitated or dependent. In this environment, the act of caring for others was naturally learned from an early age. However, the concept of family has undergone structural changes in recent years, which makes it urgent to adapt education to new emerging demands.

Nunes ¹⁶ states that, nowadays, there is an apparent absence of moral values and norms, making it important to reflect on what can be done to fight this trend. Several authors have addressed the importance and contributions of teaching bioethics at school ¹⁷–¹⁹ as a promoter of teamwork, problem solving, and self-confidence ¹⁹. However, plan constant and effective interventions must be planned.

We believe that debating concrete cases experienced by young people in their relationships—or found in social networks—and sharing opinions and feelings led by a professor with ethical training can be the first steps to awaken the interest and respect of young people for the community. If promoted from an early age, reflection and critical judgment can build foundations for the future, fostering the development of a more solidary and democratic society ²⁰.

The educational initiative focused on bioethics in schools needs to be transversal to all students, so it can play a more important role in programs based on contact with the person in different contexts and phases of life, such as nursing.

Using methods and methodologies that develop moral competence

Due to the development of new technologies, teaching becomes a challenge for teachers throughout the school path. Since early age, children know a series of incentives that did not exist a few decades ago, so occurs a growing need to develop relevant methodologies that involve the student. This situation extends to the programs of higher education, nursing, and bioethics teaching in nursing.

The literature suggests that developing teaching methodologies that combine exhibition methods with methods of simulation and problem solving will be indicated in bioethics teaching to nursing students ²¹,²². However, the simulation and discussion of real cases conducted by a teacher has been shown to be a more effective method in bioethics teaching ²¹–²⁴.

Activities such as gaming ²⁵,²⁶ and watching films, by promoting reflection and development of reflexive critical thinking ¹⁰,²⁷, also demonstrate positive effects in teaching bioethics. In this regard, Duane ²⁸ indicates the importance of teachers and students improving ethical capacity together, but also fostering creative capacity as people and nurses, developing pedagogical methods that inspire and support this creativity in clinical practice.

Teaching bioethics before and after clinical experience

The nursing course curriculum is not always similar for all educational institutions. Some schools, for example, choose to teach bioethics before clinical education while other schools teach bioethics before and after clinical teaching. The United Nations Educational, Science and Culture Organization (Unesco) ²⁹ proposes a workload of at least 30 teaching hours for bioethics, leaving this number available for each school to teach the subject.

We consider coherent to teach bioethics before the clinical practice. Then, through contact with the deontological code, students will be aware of their rights and duties as a future nurse and will also understand the objective of teaching bioethics in nursing and its professional applicability. Moreover, the first ethical dilemmas confronted by the students are seen when studying bioethics, which mirror the difficulties experienced by nurses in practice and possible solutions, developing their moral competence and decision-making skills.

However, we consider bioethics teaching after clinical practice equally important. Without clinical practice contact and real situations experience, it is difficult for a nursing student to make decisions, because care, which underlies nursing practice, has an emphasis on the relationship with others. All situations discussed in the classroom, even the ones based on real cases, are hypothetical and idealized by each student. It is only in direct contact with the patient that nurses can become aware of all the variables implicit in a decision process ³⁰. In contact with the patient, it is possible to establish a relationship of empathy, to know their preferences, their fears, their longings, their expressions, their history, family, among others. All these factors may have a burden for decision making.

A learning environment that promotes reflection and critical judgment

Transversal to all disciplines, this is a pillar of education, and not only to the bioethics teaching. For the students, it is difficult to learn if they are not allowed to question the different situations they are against if for each question pointed out he is corrected and advised to remain silent. This situation will lead them to fear and to a increasing difficulty in revealing their thoughts and expressing their feelings ¹².

Physical conditions of the learning place are not always the best, but a welcoming environment, with available teachers, that promotes dialogue and reflection, meets the indispensable conditions for quality teaching, positively impacting the training of nursing students ³¹,³².

Follow-up by clinical teaching tutors who are examples of good ethical and professional practices

Nursing bases its practice on the relationship with the other, so the remarkable moment of a nursing student's life is the contact with the patient through clinical practice. This is when the student becomes aware of their profession and experiences the first ethical dilemmas in practice. In cases where bioethics is taught before clinical education, clinical practice teaching tutors have an increased responsibility in the development of the moral competence of nursing students. Hence the importance that clinical teaching tutors are true examples of good ethical practices. Because, only then, reflection could be promoted in the classroom and an advice given at the appropriate time, on a case-by-case basis, regarding the decision to be made ¹²,³¹.

Final considerations

We consider that teaching ethics can play a crucial role in the development of the moral and professional competence of a nursing student. The essential tools for nurses’ clinical practice are reflection, critical judgment, and decision-making, which are skills that can be developed in bioethics classes through the promotion of ethical dilemmas debates experienced in clinical practice, within a learning environment where the students feel understood and stimulated to develop their reflexive critical thinking.

Considering that nursing is, by nature, the science of care, we consider it extremely important to invest in an ethics of care, focused on respect and responsibility with the other. Whether in the analysis of hypothetical ethical dilemmas in the classroom context or in clinical practice in contact with real ethical dilemmas, it is important to ensure the construction of an excellent moral and professional competence in the future nursing professional.

• This article is based on the doctoral dissertation of the first author, Vera Martins, whose realization was guided by co-author Ivone Duarte and co-directed by co-author Cristina Santos.

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Publication Dates

• Publication in this collection
  28 Nov 2022
• Date of issue
  Jul-Sep 2022

History

• Received
  11 Feb 2021
• Reviewed
  11 Aug 2022
• Accepted
  16 Aug 2022