INTRODUCTION

In the health area, a habitual behavior is observed among professionals of using knowledge about diseases and treatments (generating authority) over the passivity of those who need care - the patient (perpetuating dependence) - and this marks a strong characteristic of paternalism. For many professionals, it is difficult to assess an individual’s ability to decide on an indication based on clinical and laboratory evaluation. Often, there is still a very strong belief in professional knowledge as sovereign¹.

Involving patients in decision-making helps professionals ensure that the treatment provided reflects their preferences and values. Ethics, here understood as a reflection on moral and deontological norms and rules and the values that should guide how professionals should behave, is essential to the practice of health care, and respect for patient autonomy is present in the professions’ codes of ethics. Patients must have the exercise of their autonomy fully guaranteed. Thus, all information must be presented, allowing this autonomy to be exercised^2)-(5.

It is recommended that professionals make decisions considering clinical, epidemiological, psychosocial and ethical aspects, never forgetting that these complement each other. With this in mind, it is necessary to consider that competencies can be understood as the skills and knowledge that are acquired throughout training. When we talk about healthcare professionals, understanding the user’s role in decision-making is a competency that needs to be acquired by everyone. Thus, we must remember that the logic of training in the different specialties in some health courses, such as medicine, nursing and nutrition, including specialization in Nephrology, is focused on the idea of clinical skills, that is, education acts as a teaching guide for including the professionals into the work process, but often it does not work as Paideia (broad, holistic training with cultural identity) and perpetuates the status quo of technical, procedure-centered training^5)-(7.

The vision of skills has been changing daily, as the place of study has expanded. As authors have suggested, there is a need for training that understands the reality of the population, and not just the constant identification of diseases and pre-determined treatments. In this sense, providing the training of reflective professionals who are less attentive to the closed content of the disciplines, developing autonomy, focusing on learning to learn and the student’s protagonism, with the aim of creating care practices that go beyond the strict needs of a population that has a specific characteristic, and yes, the look at the extramural scenario that society presents^6)-(7.

Most schools that train health specialties rely on educational methods that support technological logic, focusing on imaging and equipment, dispensing with or making learning about interpersonal relationships a secondary aspect. The work of the different professionals who comprise the team must be orchestrated and aligned, to present a relationship with the user that directs the team’s form and action. The construction of knowledge occurs through collective lines of force, especially when we are talking about health care^6),(8.

When thinking about strategies to improve professional training, we must look at the national curricular guidelines (DCN, Diretrizes Curriculares Nacionais) for undergraduate courses in the health area. Since 2001, the articulation between the training of professionals and the field of health practice has been presented as necessary and essential. The resolutions show the need to promote graduates capable of working in the promotion, prevention, recovery and rehabilitation of health, through generalist, humanist, critical and reflective training to work with quality, competence and respecting the principles of ethics/bioethics, noting that health care goes beyond the technical act of care, requiring the resolution of individual and collective health problems. It is worth noting that the same is expected in the competency matrix for the training of nephrology specialists^9)-(13.

Bioethics, understood here as the concern for humans, and all non-human beings and the environment in which they live, the relationship with research and the intention of professionals, was included in the DCNs, especially to direct the training in the specificities required for graduation in the health field. This became one of the contents proposed within the transversal topics, as a desirable competency for all graduating professionals who will work providing health care. It is worth highlighting that training in bioethics for health professionals in Brazil commonly occurs through the teaching of the Hippocratic medical ethics; or the principlist approaches that guide our professional codes^2),(14)-(15.

In this sense, training is expected to occur with the discussion of content related to action, focused on respecting the autonomy of individuals, without forgetting the need to verify beneficence and non-maleficence in its applicability, in addition to the real possibility of always obtaining a view of justice and equity present in the context of harm in which professionals live daily¹. It is necessary to investigate the perspectives of training professionals who are currently working, so that there is the possibility of thinking about future training. We emphasize that there are no descriptions in the literature of this specific assessment in the training of nephrology specialists.

The aim of this study was to evaluate the ethical training of professionals working in outpatient clinics providing conservative treatment for Chronic Kidney Disease (CKD) and their knowledge of the concepts, currents, theories and teaching methods of bioethics.

METHOD

This is an exploratory, descriptive study with a qualitative approach in which professionals working in the conservative treatment of CKD outpatient clinics of four Nephrology specialist training services in Rio de Janeiro were interviewed. All 65 members of the multidisciplinary teams, including a doctor, nutritionist, nurse, psychologist and social worker, as recommended for the minimum active team¹⁶, were invited to participate.

The contact and previous relationship for the invitation was made by email or telephone provided by the heads of the services. The objectives of the research were explained, as well as how participation would occur, the researcher’s interests and concerns regarding the proposed topic, in addition to the main objectives for carrying out the study and, after acceptance, the interviews were scheduled, according to the professionals’ preference and availability. Two professionals were on vacation at the time of data collection and, for this reason, they were excluded, totaling 63 interviews in the end, of which 61 took place in person in the services where the professionals worked, in a restricted location with the presence of only the researcher and the interviewee, to guarantee confidentiality; and 2 were held virtually, through the Google Meet platform. All interviews occurred only after reading, agreeing with and signing the Free and Informed Consent Form.

The interviews took place between March and September 2022, following a structured script that contained questions related to the characterization of the population and training in bioethics: Was there a moment in your training when the concepts of ethics and bioethics were presented to you? If yes, when? How? During your training in nephrology, did you have contact with any discipline that addressed bioethics topics? Which? What contents would you like to study on the topic of bioethics in nephrology? How important do you consider the teaching of bioethical aspects in nephrology for your professional practice? Why?

All interviews were recorded in audio lasting between 5 and 20 minutes. They were subsequently coded with the letter “I”, followed by the number of occurrence, transcribed in full, without return to the participants and Bardin’s content analysis¹⁷⁾ was carried out, without using software. The pre-analysis with organization and transcriptions of the interviews in full constituted the corpus of the study, comprehending what the research participant sought to convey; the exploration of the material took place with the selection of meaning and categorization cores; in the interpretation, the inference variables present in the speech were observed. Afterwards, the contents were grouped into key indicators or topics when processing the results. At this point, it was important to observe the homogeneity and similar characteristics related to nephrology and the heterogeneities related to the professions and respective areas (medicine, nutrition, nursing, social work and psychology) in the studied context. In the last stage, the findings were made meaningful and valid, through the analysis carried out by inferences and final interpretation. Data saturation was not used, since the proposal was to interview all professionals working in the teams of the four services.

The analysis based on the theoretical framework related to Bioethics was carried out by the principlist current, focusing on the principle of autonomy and the dichotomy presented by the paternalism present in the actions of health professionals, which is related to beneficence and non-maleficence¹.

All stages of the interview were carried out by the nurse, doctoral student and main researcher, who was trained and qualified to carry out this interview. The reasons for carrying out the research arose from working in a conservative treatment outpatient clinic and the perception of the difficulty encountered in maintaining the right to exercise autonomy by the users treated at the services.

The research was carried out in compliance with Resolution n. 466/201218 of the National Health Council/Ministry of Health. The study is part of the data from a doctoral thesis entitled “Bioethical Implications in the choice of Renal Replacement Therapy: the perspective of the health professional” and was approved by the Research Ethics Committee of the proposing institution and the 4 co-participating institutions, under the following CAAE numbers: 54898422.1.0000.5240; 54898422.1.3004.5259; 54898422.1.3002.5257; 54898422.1.3001.5253; and 54898422.1.3003.5258.

RESULTS

Of the 63 professionals, 51 (81.0%) were female. The mean age was 39.88±12.23, ranging from 21 to 68 years. The year of graduation varied between 1978 and 2021; and the year of completion of the specialization in Nephrology ranged from 1982 to 2022; the average time working in Nephrology was 10.92±11.11 years, in conservative treatment 8.92±9.5 and in the institution 8.93±10.04 years. The other general characteristics of the sample are shown in Table 1.

In the analysis of the interviews, 28 categories emerged, grouped into four thematic axes: The Study of Ethics; How and what professionals learn about ethics; Relevance of the study of ethics in professional training; and the Study of ethics in Nephrology. Chart 1 depicts these categories and a summary of their meanings and main findings.

In the specific assessment of the professionals’ knowledge about bioethical concepts, it was evident that only two professionals spoke about specific theories and concepts of ethics, one of whom reported studying philosophy, and the other who said that he studied the content during his master’s degree:

I28 “We can’t be paternalistic, right? In other words, we have to accept the patient’s autonomy”.

I63 “So I learned the principles basically... Principlism, perfection. Basically, the 3 basic domains, right? of so-called perfectionism.

On the other hand, we observed the presence of concepts in some statements, without making them explicit, especially regarding the principlist theory and the autonomy of the subject. For example, one professional made it very clear how ethical principles are the basis of human action and professional performance, but without mentioning them:

I24 “I think that the question you talk about ethics in Nephrology is not so much ethics with the patient, but what the paths are, what tools that the institutions and specialty allow you to live ethics... We have to earn a decent pay, we have to! We have to be paid, but if you study medicine only thinking about money, firstly you are in the wrong place, because you don’t make money easily in medicine, you work a lot, you make money, few make money without working, other professions earn a lot more. And even so, medicine is affecting human beings at their most fragile moment. So, if I’m only looking for money, I’m not going to be a doctor, and it’s a deeper issue, I say this to my colleagues: you don’t need to have religion, you don’t need to have faith, you don’t need anything. If you take your Hippocratic oath and follow it to the letter, you are only doing good. The worst of all is that besides the fact that we’re not showing compassion, we’re not even doing the correct technique. Because the correct technique does not cause damage, it has complications, it does! But it’s within the technique and I’m not always going to be 100% in a procedure.”

DISCUSSION

The identified categories emerge as the teaching of ethics as a transversal content in the training of health professionals, as recommended by the DCNs for undergraduate courses. It is necessary for every professional to be trained in the content to work in the different sectors in which they are involved. Especially in medicine, which makes up 69.8% of our sample, professionals are expected to be trained through “professional ethics based on the principles of Ethics and Bioethics, taking into account that the responsibility of health care does not end with the technical act”¹¹.

In the competency matrix of Medical Residency programs in Nephrology, the competencies and skills to “apply the fundamental concepts of medical ethics”¹³ are expected at the end of the course. One study that evaluated the political-pedagogical projects and curricular matrices of 12 nursing courses identified that ethics is present in 11 of them, highlighting the teaching of: professional ethics, bioethics, professional legislation in nursing, ethics and technoculture, society and contemporary times, social practices and ethics, among others¹⁹.

On the other hand, the majority of interviewees reported not having studied ethics during training in Nephrology (specialization or residency) and there were reports of learning these contents while carrying out research or following professional habitus, that is, with the reproduction of what is observed during training or even when observing the performance of colleagues and starting decision-making with similar conducts and actions²⁰.

A study with residency preceptors identified that many of them do not understand broader levels of knowledge about Ethics and Bioethics, paying attention to specific professional ethics content and, therefore, they may have difficulty disseminating knowledge among the residents who accompany them. To improve this knowledge, the authors suggest carrying out training activities, valuing interdisciplinary and interprofessional approaches and point out that it is necessary to train teachers and establish permanent education, so that ethical and moral training is not the product of chance or continues on the margins of curricula, as a less important content^21)-(22.

Many statements also emerged that express the importance of ethics in the professional’s routine, being seen as the basis of action and the importance of content in training and its importance for life, corroborating Oliveira and Oliveira who identified that the majority (89%) of students who are studying medicine consider the topic extremely important¹⁷.

Moreover, there is a strong presence of statements about the interest in studying ethics in Nephrology. On the other hand, the professionals also portrayed the irrelevance of the content taught during their training and the deficiency in this content. Among the medical students, 34.5% considered the learning of bioethics to be regular and 21.8% considered it to be poor. Of the 276 medical schools in Latin America evaluated, 118 of which are in Brazil, the majority are still “focused on more technical than humanistic training”, with these minimum workloads for the teaching of ethics and bioethics, when compared to the hours available for the learning of clinical content^7),(23.

A study carried out with students attending the last year of dentistry, physical therapy, pharmacy, nursing and physical education courses emphasized that knowledge about bioethics becomes even more relevant for working health professionals, as Biondo “the support of the principles that guide bioethics, since its formation, can guarantee quality in health care based on the assumptions of dignity, integrity and autonomy of the subjects” (p.10), thus favoring the defense of life and having an impact on the patient-professional relationship. We highlight the importance of deepening knowledge and discussions in the training process about the applicability of the principalist theory, since it supports the entire process of action^1),(24.

We reiterate that, in our sample, only two professionals mentioned knowledge of bioethical theories and specific ethical concepts, these being specifically about the Principlism of Beauchamp and Childress. Perhaps it is extremely important to think about how much ethics is part of the professional’s basic performance skills and it is important to review curricula and the way this content is presented. Biondo et al. corroborates the theoretical confusion of students in health courses when conceptualizing bioethics, even though they have knowledge about the objectives and concepts of bioethics, as it aims at social good, respecting beneficence, non-maleficence, justice and autonomy. In this sense, we reinforce the importance of thinking about how to work with these contents that are considered the basis for professional training and transversal to all disciplines^1),(24.

A study carried out with nurses identified the professionals’ difficulty in understanding their administrative, care, educational and research duties and competencies, as they have not been well defined, perhaps due to the lack of reflection on their professional practice. Although the article does not associate competency and ethical ability, we can question whether the findings of this study are not related, because as the authors concluded, knowledge and skills incorporated through training and practice can direct the ability to act effectively in certain situations ²⁵.

The concept of moral competency and the importance of developing the moral judgment of professionals is presented so that they can evaluate different situations and act in accordance with the moral principles learned during training. We emphasize that the training services in which the interviews were carried out can be used as a laboratory for contact with real ethical dilemmas during work in Nephrology. Medical students at a university in Rio de Janeiro considered respect, responsibility, patience and humility to be the most important moral values ​​for medical training, and responsibility, respect, patience and prudence are described as the most encouraged during training^22),(26.

In this sense, competencies must be incorporated by three main elements: knowledge (to know); ability (know-how) and attitude (want-to-do). Oliveira and Oliveira demonstrate that the competencies can contribute to appropriate attitudes in different situations, such as conflicts of interest, in relationships with patients and their families, with fellow doctors and other members of the multidisciplinary team, as well as with their superiors in the institution, health insurance companies, the pharmaceutical industry and others^23)-(25.

There is a predominance of ethical incidents and complaints involving recently graduated nursing professionals, and the principles of non-maleficence and justice are the most violated by professionals, but there is also a violation of autonomy and beneficence. Nora et al. reinforce that educators, by teaching ethics, will be able to avoid negative and morally challenging effects that professionals may experience later. We suggest that ethical training be implemented in all training courses in Nephrology, for different professions, through the provision of content that will favor the development of competencies and attitudes of future professionals and can help provide care to users who have conditions considered to be difficult and generate ethical dilemmas ^19),(27.

It could be interesting to start teaching through the topics suggested by the interviewees themselves, such as: “the moment to guide patients so that they can know about possible treatments; initiation and preparation of dialysis; transplants; expanded criteria in kidney transplantation; Palliative nephrology; end-of-life care; confidentiality and social media; the approach to patients who refuse to undergo dialysis; when to interrupt dialysis in a patient with cancer, or elderly patients, indication of dialysis in an elderly patient, those with cancer or degenerative diseases”.

For this to occur, it is necessary for teachers to become aware of their social role, and how discussions related to these topics are of the utmost importance to promote a graduate with all the characteristics we desire. A systematic review that sought to identify which studies demonstrated the important dimensions of medical training and which are sometimes left aside during the undergraduate course highlighted that ethics can be approached systematically and with pedagogical methods already validated in the literature and that they can add skills, removing fundamental competencies for training from the hidden curriculum^22),(28.

Reinforcing everything that was presented, an integrative review also highlighted the importance of teaching bioethical concepts to specialists and residents in Nephrology. The authors suggest that teaching this content can directly impact compliance with bioethics and allow a better understanding of the experienced ethical dilemmas, in addition to a better understanding of the vulnerability of patients and providing more humanized care²⁹.

For this reason, when thinking about training in all areas, including Nephrology, it is essential to think about education, so that professionals can recognize their limits and consciously assume their own vulnerability in the presence of ethical conflicts that may arise during the performance. Training with the development of critical awareness and positioning attitude in situations can direct action. In this sense, the fragility of the professionals, even if they do not recognize themselves as such, needs to be perceived, expressed and, above all, discussed. The main focus cannot be directed to the patient’s fragility, related to the finitude of life and the therapeutic impossibility within the scope of Nephrology. Professionals are constantly at risk of exposure, especially when one observes the ethical issues implicit in their work⁸.

CONCLUSIONS

With this study, we can highlight the reported lack of interest and little importance related to the study of ethics in the training of specialists in Nephrology, which, according to the reports, may be related to the forms of content presentation, in addition to the difficulty the professionals have in understanding the importance of studying contents that permeate the clinic and that is essential for their performance. However, there is a clear perception of how much ethics is present in the work context, especially in health, and that professionals reinforce the collective awareness that ethics is something intrinsic, permeated through the habitus, and that it does not need to be studied, as human action is based on principles such as justice, beneficence and non-maleficence.

However, there is no way to develop ethical skills that will become attitudes, without the necessary knowledge to understand the role of the other as an individual who needs care but must be able to exercise their autonomy and make decisions regarding their life and treatments. Therefore, it is necessary to review the curricular matrix of training courses for specialists in Nephrology, especially the professions that were interviewed in this study, and we suggest the inclusion of contents related to ethics and bioethics that may favor the knowledge and desire to do by the professionals who will work in scenarios where care goes beyond renal health, but cares about taking care of the individual and all the needs they have due to the changes caused by the inclusion of renal replacement therapy in their lives.