ARTÍCULO ORIGINAL / ORIGINAL ARTICLE/ ARTIGO ORIGINAL

Ethical implications and decision making in care education process

Implicaciones éticas y toma de decisiones en el processo de enseñar a cuidar

Envolvimentos éticos e tomada de decisões no processo de ensinar a cuidar

Layse Kelle Silva¹; Paulo Roberto dos Santos Marins²; Tábata Cerqueira Nascimento Nobre³; Iracema da Silva Frazão⁴; Darci de Oliveira Santa Rosa⁵

¹Undergraduate nursing student. Universidade Federal da Bahia (UFBA), Brazil. email: laysekelle@hotmail.com.

²Undergraduate nursing student. UFBA, Brazil. email: rochamarin@hotmail.com.

³RN, Ms.C candidate. UFBA, Brazil. email: tabatacn@gmail.com.

⁴RN, Ph.D. Professor. UFPE, Brazil. email: isfrazao@gmail.com.

⁵RN, Ph.D. Professor. UFBA, Brazil. email: darcisantarosa@gmail.com.

Receipt date: May 26, 2013. Approval date: Feb 10, 2014.

Article linked to research: Dilemas Éticos no exercício de ensinar e/a cuidar nos cenários de prática do SUS.

Subventions: Bolsas de Iniciação científica da Fundação de Amparo a Pesquisa do Estado da Bahia -FAPESB e do Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq. Uma bolsa de cada órgão mencionado.

Conflicts of interest: none.

ABSTRACT

Objective.To determine ethical implications for nursing practice at the point of decision making by nursing professors in practice area. Methodology.A qualitative method was adopted, with use of semistructured interviews with sixteen nursing professors who delivered care at a teaching hospital in Salvador, Bahia, from May to June 2011. The methodological reference used was the discourse of the collective subject (DCS) by Lefévre and Lefévre. Results.In response to DCSs, the following subjects appeared: "Ethics is fundamental and of vital importance in the decision making process," "searching for knowledge and research to identify problems and solutions, including alternatives and support for decisions," and "to act in the best way." Conclusion.Professors who provide education about patient care also delivered care. They have the responsibility to consider the ethical implications of decision making because they stimulate fundamental reflection and could positively influence future nursing professionals.

Key words:decision making, nursing, ethic, education, graduate.

RESUMEN

Objetivo.Conocer las implicaciones éticas en el momento de la toma de decisiones por parte de docentes de enfermería en el área de práctica. Metodología.Cualitativa con entrevistas semiestructuradas realizadas a dieciséis enfermeros docentes que realizaban prácticas en un hospital escuela en la ciudad de Salvador - Bahia, en los meses de mayo y junio del año 2011. Fue adoptado como referencial metodológico el Discurso de Sujeto Coletivo (DSC) de Lefévre y Lefévre. Resultados.De los DSC surgieron las siguientes temáticas: "la ética es fundamental y de vital importancia en el proceso de toma de decisiones", "trabajar en la búsqueda de conocimientos e investigaciones para poder identificar los problemas y solucionarlos, encontrando alternativas y fundamentar las decisiones" y "ejecutar las acciones de la mejor forma." Conclusión.Los docentes que trabajan en el proceso de enseñar a cuidar, también cuidan y tienen la responsabilidad de considerar las implicaciones éticas en el ejercicio de toma de decisiones, pues estas estimulan una reflexión fundamentada y pueden influenciar positivamente al futuro profesional de enfermería.

Palabras clave:ética en enfermería; toma de decisiones en salud, educación.

RESUMO

Objetivo.Conhecer os envolvimentos éticos para a prática da enfermagem no momento da tomada de decisões de docentes de enfermagem na área de prática. Metodologia.Foi adotada uma metodologia qualitativa com entrevistas semiestruturadas realizadas a dezesseis enfermeiros docentes que realizavam práticas num hospital escola na cidade de Salvador - Bahia, nos meses de maio e junho do ano 2011. Foi adotado como referencial metodológico o Discurso de Sujeito Coletivo (DSC) de Lefévre e Lefévre. Resultados.Dos DSC surgiram as temáticas envelope: "a ética é fundamental e de vital importância no processo de tomada de decisões", "trabalhar na busca de conhecimentos e investigações para poder identificar os problemas e solucioná-los, encontrando alternativas e fundamentar as decisões" e "executar as ações da melhor forma." Conclusão.Os docentes que trabalham no processo de ensinar a cuidar, também cuidam e têm a responsabilidade de considerar os envolvimentos éticos no exercício de tomada de decisões, pois estas estimulam uma reflexão fundamentada e podem influenciar positivamente ao futuro profissional de enfermagem.

Palavras chave:ética em enfermagem; decisões, educação superior.

INTRODUCTION

Competence in ethical decision making is a fundamental attribute for the education of nursing professionals. Making decisions requires ethical reflection because this process is indispensable at institutions and other health service facilities. A decision based on the ethical principle of beneficence could be transformed into maleficence depending on the way in which it is transmitted or executed.¹ Ethics in this context is understood as a responsibility to direct human behaviors and decision making in such a way as to assist with reflection, conduction, and selection of the best way to act in specific situations.

The decision making process affects relationships among those involved in health care, such as workers, families, health professionals, and health managers. Nursing team performance involves care, health management, and education, among other activities. All these roles require aptitude and competence to make decisions. A competent professional has the ability to use, integrate, and mobilize his/her knowledge by using reasoning, reflection, argumentation, ability to build relationships, background from previous experiences, creativity, and other resources.

Contemporary nursing practice requires several competencies from the professional that could be understood as "the ability that nurse must have to be, based on his/her knowledge, able to mobilize the team correctly and make adequate decisions in each situation that appears."^2,3 Nursing professors must be aware of current social demands and technological advances, aiming to prepare students for more a complex, plural, and open society. This scenario demands work from professors and students involving stimulation of reflection, investigation, and construction of students' knowledge; professors must take into account individual and collective considerations so that students is able to face collective pressures and appreciate different viewpoints when handling ethical conflicts.^4,5

Nursing higher education must prepare new professionals not only to deliver care and promote well-being but also to confront and transform health conditions/disease and quality of life by using conceptual competencies, procedures, and attitudes.⁶ In a practical context, the essence of nursing entails integration of specific abilities (consistent theoretical knowledge and dexterity) with care of human beings. In this sense, nursing as a moral practice requires decision making that is done in the context of specific real-life conflicts and always considers the norms that are judged appropriate. This could be considered a moral-practical dilemma. When someone needs to make a decision and reflects the best pathway to take, he or she must define what is good or poor or what is right or wrong; this is configured as a theoretical-moral problem, that is, an ethical problem.⁷

In the daily life of nursing professionals, decision making involves direct care to patients and families. However, It also often becomes a learning opportunity for students at health units, who observe the attitudes and behaviors of professionals in that area. This gives the professional a perception different from his/her own experience, one that reflects the mindset of those who are beginning their professional education.⁸

The objective of this study is the ethical implications of decision making among nursing professors and mentors. The research question was, "What are the ethical implications of nursing professors and mentor practices in situations that involve decision making?" On the basis of this question, the present study aimed to determine the ethical implications of nursing practice of professors and mentors in decision making.

METHODOLOGY

This was a descriptive, exploratory study with a qualitative approach. This type of study was chosen because the objective of our study is considered an intersubjective phenomenon. The main objective of an exploratory study is to improve the understanding of ideas or institutions, whereas a descriptive study enables researchers to evaluate characteristics of a group by collecting opinions, attitudes, and beliefs of a given population.⁹ Our study was conducted at a large hospital in Salvador, Bahia, northeast region of Brazil. Professors, mentors, and students from the nursing program of the Universidade Federal da Bahia (UFBA) practice at this institution. In compliance with the ethical rules governing research with human subjects, provided in Resolution 196/96 of the National Health Council of Brazil,¹⁰ this project was submitted to and approved by the Research and Ethical Committee of Hospital Ana Neri (CEP- HAN), protocol no. 67/11. The research was conducted only after two copies of written informed consent was obtained from volunteers; the second copy was given to the participant.

Of 20 nurses, we included 16 who fulfilled the following inclusion criteria: professor or mentor from the nursing program in theoretical/practical disciplines or supervised training, onsite at the teaching hospital during the data collection period, and availability for interviews. We considered professors to be nurses who were affiliated with the teaching institution and who followed up students in practices developed in the hospital environment but did not work in the health institution. Similarly, we considered mentors to be nursing professionals who voluntarily followed up with students and worked at the health institution.

Data were collected between May and June 2011 using semi-structured interviews with closed-ended questions on duration of formal education, duration of time teaching, and time spent acting as a mentor. We also included six open-ended questions: two questions of approximation and four of guidance. The questions of approximation were as follows: (1) Have you ever experienced decision making during your practice? (2) Describe a situation of decision making experienced during your practice as a professor/mentor. Questions of guidance were the following: (3) Point out actions you performed to take a decision. (4) What do you understand is meant by "ethics in the decision making process"? (5) Describe how ethics is implicated in the decision making process in the practice of delivering care. (6) Explain how ethics is implicated in the decision making process in teaching practice.

The discourse of the collective subject (DCS) method was used to analyze data on the basis of the perspective of Lèfevre and Lèfevre,¹¹ which is defined as "a way or manner to make the collective speak directly." This strategy of discourse analysis aims to collect the personal characteristics of subjects of the research.

Interviews were transcribed in full and numbered according to order of collection as follows: E1, E2 ... E no). Questions of approximation were named A1 and A2, and questions of guidance as N1, N2, N3, N4. Interviews were read in full, placed in charts, and analyzed. Rigor was sought by using following described steps: (1) analysis of all answers given for the same question to; then proceed to the next question; (2) identification and highlighting of key expressions of main ideas; (3) identification of main ideas from key expressions (or nucleus that anchors main ideas; (4) identification and grouping of main ideas with the same meaning or equivalent meaning; (5) creation of a main synthesis idea that express all main ideas of the same meaning; and (6) analysis of key expressions and the nucleus that supports them for the development of main ideas and posterior construction of discourses. From this analytic process of discourses obtained from subjects, three dimensions of discourse from the collective subject emerged: ethical implications of care practice, ethical implications of practice of teaching care, and ethical implications of decision making in teaching and care among nursing professors and mentors. This article analyzed the main ideas concerning the ethical implications of decision making on teaching and caring among nursing professor and mentors.

RESULTS

According to data provided by interviewers, we observed that eight participants were mentors and six were mentors and professors in theoretical-practical disciplines. Only two participants declared to be professors of theoretical disciplines and at that time were acting as nurses at the institution. Therefore, teaching was characterized as theoretical-practical wherein professors taught classes of theory and of theory-practice.

We collected data on duration of formal education and of teaching. Two professors had spent the same amount of time teaching (ten years) and in professional experience. Among mentors, five had graduated less than ten years previously, and three had graduated more than ten years previously. All mentors had at least ten years of teaching experience. Among professors/mentors, five had graduated up to ten years ago, and only one had graduated more than ten years ago. Six had up to ten years of teaching experience. Such findings revealed that participants began teaching and mentoring soon after graduation.

One of mentors informed us that she began teaching even before her graduation. Duration of formal education in this case was not a factor that compromised teaching. These professors/mentors, upon graduation, became interested in teaching, with the aim of gaining more knowledge.

Twelve discourses emerged on ethics in the decision making process and the ethical implications for practice of care and teaching, which were distributed among five main ideas: (1) ethics is fundamental to guiding the decision making process, (2) the initial step entails identifying the problem, (3) seeking to understand the context of a problem in order to identify alternatives and to support decision, (4) it is important to consider institutional rules before making a decision and to execute the action in the best way and (5) acting in the best way possible is mandatory.

Professors and mentors expressed that decision making in teaching and care practice is based on ethics and must be founded on the following actions and attitudes: identifying the problem, seeking to understand the context of the problem in order t to identify alternatives on which to base the decision, considering institutional rules for decision making, and executing the plan of action in the best way as possible, according to the following discourses:

Main idea 1 is that ethics are fundamental to guiding the decision making process. Response to DCS 1: We can't make any decision not based on ethics. Because without ethics how should I guide the decision making process? That is, to decide you must be ethical. [One should have] ethical behavior. This assures the decision making. Response to DSC 2: It gives safety to students and shows what really is suitable to nursing. You should not cross the line.

Main idea 2 is that the initial step consists of identifying the problem. Response to DSC 3: We raise problems and identify key situations that lead to a final decision. DSC 4 reinforces this idea when affirming that making a decision is to put into practice everything that was learned on ethics, always prioritizing the quality of patient care, and therefore making the right decision. Such affirmations are endorsed by DSC 5: So, first it is necessary to discern, try to listen both sides, and (...) to have a common sense of what is right. You should try to be honest and fair as possible.

Main idea 3 is that seeking an understanding is done in the context of the problem in order to identify alternatives and to support decision DSC 6 affirms that, Based on theoretical knowledge of problem-solving I end up putting into practice what I learned in college before making my decision. Response to DSC 7: The action is to prioritize patient care. Therefore, decision making is in agreement with patient clinical features in order to determine what assistance will be immediately delivered.

Main idea 4 states that it is important to consider institutional rules before making a decision. The response to DSC 8 affirmed, I talk with professionals to know the behavior expected by the institution. You have to try to address institutional rules.

Main idea 5 is that acting in the best way possible is mandatory: I act. I act in the best way possible (DSC 9). If you are not ethical and do not have behavior I think it is quite hard to provide good lessons to anyone.... We must be ethical as far as possible with professionals or patients.... In addition, when you are teaching, there are behavioral ethics because when you have an inadequate behavior, students end up linking it to you for the rest of their career (DSC -10).

DISCUSSION

The discourse on understanding ethical implications in the decision making process considers ethics to be fundamental to guiding this process and affirms that the professional is acting with coherence regarding the individuality of each person. In patient care education, professors and mentors often face conflict that requires an ethical approach and an adequate decision. For this reason, ethics become imperative to guiding how someone's behavior and actions towards him/herself, others, and the environment should be. ¹²

Human beings, independent of their motivation, are included in the ethical environment, and they make decisions in the setting of conflicts and dilemmas. Using ethics to guides decision making leads to reflection and can help support the belief in what is considered correct; thus, it allows making the right decision throughout the human lifecycle.¹³

Professionals' decisions and nurses' qualification influence not only the delivery of care to patients and resolution of ethical problems, but also the learning process and professional development of students. Because students do not have enough knowledge and experience, they need supervision of experienced professionals during practice.⁸

Nursing professionals, professors, and mentors are making decisions all the time. Most of the times, they do not even perceive that they are making decisions. Assigning an activity to someone, choosing what substance to use in a bandage, or even deciding to not take any action when faced with a problem - All these involve making decisions. In making a decision, it is necessary to know the subject, based on ethical issues, with the aim of achieving the best solution.

There is no way to decide whether someone could identify a problem that is actually happening. A possible pathway to achieve ethically conscious actions is to look around the world¹⁴ and to have common sense. Making a fair decision is hard, especially if one attempts to do so without asking questions and reflecting. Professors/mentors affirmed that they use common sense based on reality and ponder their actions by seeking society's values, ethical principles, and their own personal values.

In making a fair decision, it is important to obtain directly relevant information. Knowledge is a relevant factor that enables understanding of the context of a problem situation; it enables the decision maker to evaluate and consequently provide subsidies in the attempt to solve the problem. Nothing could be accomplished if no in-depth knowledge is available to be mobilized by the decision maker to resolve a specific situation. Data, facts, and information must be sought in order to reduce uncertainty about a situation or problem and to establish priorities in care planning.¹⁵

Planning evolves to verify all variables, possible alternatives, and management approaches concerning the environment; that is, to always know the behavior expected by the institution. Therefore, the complexity of the decision making process is perceived, because the individual must act ethically, to involve technical-scientific knowledge, practical experience, and respect for institutional rules, and the decision maker must know what behavior can be displayed in an institution so that the decision is in agreement with the institution's expectations. It is imperative to understand that the organization or institution may influence the decision making process because persons who stay or grown within an organization are those who pursue the same values and beliefs expected from such an organization.¹²

It is well known that mentors and professors seek to apply their actions in the best way possible to achieve an objective. For this reason, feasible implementation of actions must be sought. Each step approached influences the other steps and all groups involved in the decision making process.

Actions should be always conducted in an attempt to promote the common good.¹² The adoption of the principle of beneficence at the time of decision making is proposed; this is linked to the action of doing good, not causing harm to others, and favoring quality of life.¹⁴

Students' behavior might be influenced by professors' behavior. For this influence to take place, professional education must invest in the development of competencies. In addition, when professors or mentors are evaluating the student, they must prioritize not only the reproduction of theoretical knowledge but also the ability to apply such knowledge in real-life situations that involve decision making.⁴ Therefore, professors do more than transmit theoretical knowledge; they must show that practical abilities must be coherent with what they say, feel, and do.²

CONCLUSION

Education on providing patient care is inherent to nursing. This study sought to determine the ethical implications of the practice of teaching on providing care and especially decision making. Ethics are fundamental in nursing practice, and to be ethical, an individual should understand what competencies and limitations he /she has. In both teaching and delivering care, the individuality of those who receive the care should be considered, and the patient context must be respected and valorized. Using ethics to guide patient care provides the cornerstone that allows professionals to safely deliver that care.

Diverseness is an ethical exercise that is based on the nurses' reflection in decision making. To the participants of this study, ethical implications in teaching are correlated with care and led to ethics being a guiding process of learning during professional education. In addition, we observed that professors/mentors must use ethics when establishing therapeutic relationships with patients and families and interpersonal relationships with their working team.

According to the participants, professors/mentors serve as a model to students, and the way they act in the process of teaching and providing patient care helps create a reference projected by student to his/her professional future. The participants understand the importance of ethics both in the classroom and in practice, and seek to transmit to students both knowledge and considerations of what is ethically correct, even in the face of unethical behavior observed in the field, with the aim of benefiting students' reflections. Nursing professors/mentors understand that to make a decision without considering ethical implications is impossible because such implications guide the supported reflection, leading the professional to always act with coherence and respect for patient individuality. They make decisions that respect his/her beliefs and values.

Actions performed during decision making by professors/mentors did not follow a theory model but do share some stages or steps in common, such as: identifying the problem, evaluating the situation, using common sense, seeking knowledge, creating plans, following institutional rules, prioritizing the patient, executing the action in the best way, and evaluating actions to verify results. It is relevant to consider that criteria and models for decision making are not determined and that decisions are abilities developed in practice and with practice. The professional should be well-prepared to analyze complex situations, make the right choices, and make decisions that consider all possible alternative solutions to the problems and acknowledge that, in all aspects of life, ethical issues surround us.

The present study enabled us to understand how the decision making process takes place and its ethical implications in teaching practice. We observed that nursing professional activity is closely related to decision process. Professors/mentors make decisions during their practice in teaching and providing care with regard to procedures that are done, even in very common situations (e.g., behavior in classroom, elaboration of teaching plans, distribution of students at practice field-in other words, all the time). We suggest that professors who are conscientious of their role should view decision making as a stimulus to encouraging responsibility during the learning process; decision making must be prioritized by the professor as a moral factor to be acquired by students as they learn.

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