Nephrologist training: a bioethical analysis

ABSTRACT

Introduction:

The training process in which the professional is inserted will have an intense relationship with the way they will face everyday situations, especially because they highlight bioethical conflicts.

Objective:

to evaluate the ethical training of professionals working in outpatient clinics providing conservative treatment to Chronic Kidney Disease (CKD) and their knowledge of bioethical concepts, currents and theories.

Method:

This is a cross-sectional, descriptive study with a qualitative approach in which 63 professionals were interviewed, including doctors, nutritionists, nurses, psychologists and social workers, working in CKD conservative treatment outpatient clinics in four training services for Nephrology specialists in Rio de Janeiro, between March and September 2022. The interviews were recorded, transcribed and verified using Bardin’s technique.

Result:

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. The assessment of the professionals’ knowledge about bioethical concepts showed that only 2 professionals spoke about bioethical theories and specific ethical concepts. The difficulty for professionals in understanding the importance of studying content that permeates the clinic is clear.

Conclusion:

There was a lack of interest and little appreciation of the study of ethics in the training of specialists in Nephrology, associated with the professionals’ difficulty in understanding the importance of moral competence for effective, humanized and quality medical practice.

Keywords:
Bioethics; Nephrology; Health Human Resource Training; Teaching

RESUMO

Introdução:

O processo formativo em que o profissional está inserido terá intensa relação com a forma como ele se colocará perante as situações do cotidiano de atuação, especialmente as que evidenciam conflitos bioéticos.

Objetivo:

Este estudo teve como objetivo avaliar a formação ética dos profissionais atuantes em ambulatórios de tratamento conservador da doença renal crônica (DCR) e o conhecimento deles acerca dos conceitos, das correntes e das teorias bioéticos.

Método:

Trata-se de um estudo transversal, descritivo, de abordagem qualitativa em que foram entrevistados 63 profissionais, incluindo médicos, nutricionistas, enfermeiros, psicólogos e assistentes sociais, atuantes nos ambulatórios de tratamento conservador da DRC de quatro serviços de formação de especialistas em nefrologia do Rio de Janeiro, entre março e setembro de 2022. As entrevistas foram gravadas, transcritas e analisadas pela técnica de Bardin.

Resultado:

Na análise das entrevistas, emergiram 28 categorias agrupadas em quatro eixos temáticos: estudo da ética; como e o que os profissionais aprendem sobre ética; relevância do estudo da ética na formação profissional; e estudo da ética em nefrologia. A avaliação do conhecimento dos profissionais acerca dos conceitos bioéticos evidenciou que apenas dois falaram de teorias bioéticas e conceitos específicos de ética.

Conclusão:

Evidenciaram-se desinteresse e pouca valoração do estudo da ética na formação do especialista em nefrologia, o que foi associado à dificuldade dos profissionais em compreender a importância da competência moral para uma prática médica efetiva, humanizada e de qualidade.

Palavras-chaves:
Bioética; Nefrologia; Capacitação de Recursos Humanos em Saúde; Ensino

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.

Table 1
Overall data of professionals working in a CKD conservative treatment outpatient clinic.

Characteristic		N (%)	Total
Professional training	Doctor	44 (69.8)	63 (100%)
	Nurse	7 (11.1)
	Social worker	3 (4.8)
	Psychologist	2 (3.2)
	Nutritionist	7 (11.1)
Highest academic degree	Graduation	1 (1.6)
	Specialization	33 (52.4)
	Master’s degree	17 (27.0)
	Doctorate degree	12 (19.0)
Do you have another professional background (in addition to the one you are working in at the time of the interview)	Yes	3 (4.8)
	No	60 (95.2)
Specialization in Nephrology	It is currently ongoing	22 (34.9)
	Course Completed	31 (49.2)
	Not a specialist	10 (15.9)
Type of specialization Course	Residency	46 (86.8)	53 (100%)
	Lato sensu specialization	7 (13.2)
Place where you attended the specialization	UERJ	27 (50.9)
	UFRJ	16 (30.2)
	Others	10 (18.9)

• Source: The authors.
• ^a
  Others include: Luiza de Marilack; Hospital da Beneficência Portuguesa; Hospital Federal de Bonsucesso; Hospital Federal do Andaraí; Hospital Universitário Gaffrée e Guinle; Pontifícia Universidade Católica do Rio (PUC RIO); Universidade Federal de Juiz de Fora; Hospital Federal dos Servidores do Estado do Rio de Janeiro; Conselho Regional de Medicina do Rio de Janeiro (CREMERJ); Escola Paulista de Medicina.

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.

Chart 1
Categories emerged from Bardin’s content analysis carried out in interviews with professionals working in a CKD conservative treatment outpatient clinic.

The Study of Ethics	When they studied ethics	54 (85.8%) reported the study at all levels of training: undergraduate, specialization, master’s degree, doctorate and post-doctorate; 3 (4.7%) reported not having studied; 6 (9.5%) think they did not, are not sure or do not remember.
	Study of ethics in the specialization in Nephrology	Only 6 (11.4%) reported having studied ethics during their specialization in Nephrology. 1 (1.8%) reports that they will have the content but have not yet had the module. All the remaining 46 (86.8%) denied the study.
	Importance of the Content on ethics in training	It was a very present speech. 47 (74%) interviewees mentioned the topic. The adjectives used to express this importance: extreme, very, relevant, primordial, necessary, interesting and fundamental.
	How important the study of ethics was for the professional	There is a description that was essential for the improvement in care. One statement summarized what was expressed by the others: “So, it is important for us to know how to deal with it, even with respect to the patient’s autonomy, what we offer, if there will be any benefit in their life, really?” (I60)
	They do not know what would be important to study in ethics	It was reported that the lack of knowledge is related to the lack of study of the topic and the lack of specific knowledge. The difficulty in formulating doubts on the subject also emerged.
	Irrelevance of the content taught	Statements emerged that learning was minimal, often in disciplines at the beginning of the course and, for this reason, the professional does not even remember the specific contents or what it is about.
	They relate their training many years ago with not studying ethics	3 (4.8%) deny the study of ethics and relate it to long-ago training: “At the time I studied Nephrology, this was not used. (laughs)” (I10 - graduated in 1987); “I graduated approximately 30 years ago and I have a very strict training in the medical part” (I17 - graduated in 1988); “as it was in the early 90s, this was not common” (I50 - graduated in 1996).
	Ethics in current training	2 (3.2%) reported that the content was in their training, as they went through “more modern curricula”.
	Possibility of linking teaching, research and extension	As they are professional training centers, 2 (3.2%) reported that there is the possibility of working on the teaching of bioethics together with the development of research in the service and in extension activities.
	Lack of time to study ethics	Despite the interest in the topic, there were reports from 3 (4.8%) interviewees about the difficulty of reconciling the study with the work routine. “I just didn’t have time in the face of the reality here of starting a job, right?” ... I find it interesting, but I haven’t had time yet” (I34); “I think that if I could, I would have more contact, you know, with this subject, yes” (I54);I, I try, I try to think about it, but I don’t, I never delved into it” (I63).
How and what professionals learn about ethics	What they studied about ethics	48 (76.2%) reported having studied the concepts of ethics or bioethics, especially in undergraduate studies.
	Other ways of learning ethics reported	The learning of contents was mentioned, such as: research in ethics; professional ethics; participation in professional council; Inclusion in the ethics committee.
	Studied ethics in Nephrology in other places	The professionals report contact with ethics in congresses, lectures, books, texts, independent study or in the discussion of cases in teams.
	They studied ethics by working in other sectors	There were reports of working in a non-oncological palliative care team by 2 (3.2%). An interesting statement was: “I left a year at the maternity to go to Nephrology and there are completely different characteristics, including our ethical position to work with each patient” (I35).
	How Ethics Was Taught	There was neglect when portraying how the content was taught: “But I think it’s very bad too. It’s very... poorly approached, not very didactic” (I13); Discussion is more in the classroom, not so much in dealing with the patient” (I32).
	Deficiency in the content taught	Terms such as; gap, little, I don’t even remember, little access, little knowledge, very loose, a deficiency, the course was very complete, but this part was not included, it is not the axis, and it does not guide, this is missing and lacking in medical courses. “I think this is something that we don’t have a determination and we don’t have adequate training to actually do this (laughs)” (I28)
Relevance of the Study of Ethics in Professional Training	Why professionals seek to study Ethics	To: do research; do the right thing; try to make as few mistakes as possible; be able to protect yourself too; doctor-patient relationship; to be able to treat better. In Nephrology specifically, it was quoted: “I stopped to think about it exactly when it is... recently, finally, this issue of the consideration of living donor transplantation was created” (I58)
	Ethics as the basis of professional performance	The statements portray that ethics is the basis of professional performance, not only in Nephrology, but in all areas, and that there is no way to act without this knowledge; It is necessary to be aware that the focus of care is the patient and pay attention to doing the best for them. It is necessary to be ethical with: the team, the user and their family.
	Ethics in the professional’s routine	It was one of the most present categories. There are reports that it is practiced daily, without realizing it; it “moves” the professional and their commitment. From this perspective, there is improvement in conducts as the experience increases, favoring the care provided and self-protection. Routine issues that can generate conflicts: different user needs and the presence of the industry.
	When the professional practices ethics	The practice of ethics in Nephrology was cited: “when we allow the patient, you know, to make their choice of therapy... when we guide them in relation to the treatment” (I1); “so that I can have respect for the patient, so that I can have a good, a good development of my work, it’s... so that I can also respect the work of the other professional” (I12);to deal with the patient, and with the suffering of others” (I17); On the other hand, it was emphasized that: “the environment, the institution you live in and the specialty... it will limit you or not in the exercise of your ethics” (I24).
	Professional habitus / example of another professional	The way you learned to use ethics: “But, in fact, you end up taking a lot of examples, right?” ... “the day-to-day, observing the other professionals, the way they acted” (I3); “because we see a lot of things like this talking to the staff, in the evolution of the cases” (I32); “It’s a little bit of the experience, right? so I put mine there, my speech with the patient is always very similar, right? it’s like that, let’s say so much talking, right? we already have more or less one, something in our heads like how we approach, how we talk, trying, as much as possible, you know, to particularize it like this for each patient, right?” (I49).
	Studying opens horizons	The importance of training and how much it has contributed to the growth of the professional was reported: “And this has, I have learned a lot, I have opened, opened my horizons a lot, right?” (I25); “Yeah, for sure right? we always want to learn more, right? aaa...this, the things change too” (I50)
	Importance of Ethics dissemination	The professionals portrayed that the disclosure of ethics can be the differential for the performance: “I think that ethics today should be more disseminated ... But this ethics focused on bioethics aimed at patients, I think it should be more disseminated, not studied as any specific topic” (I1); “Not with Nephrology itself, but with general medical training... But this is important for care, right? But this is not related to nephro, it is general patient care, you know?” (I63).
	Importance of ethics for life	There was a consensus on the importance of ethics not only for professional training, but for life and for society as a whole: “Everything always has bioethics and ethics” (I22);in the treatment, most obviously, better, right? of any human being it is fundamental” (I50); “it is mainly related to personal and, sometimes, cultural decision... like, religious” (I41). And that after the study of ethics, the professional was able to understand how wrong some human attitudes and actions are. However: “I think that society unfortunately does not understand what ethics is and when we transport the problem of society to the focal problem within Medicine, this is another conflict... What in my view today is the structure of society is very bad. Because people don’t know what ethics is, right?. These, here and there, we are faced with very complicated situations, right?” (I25).
Study of ethics in nephrology	Nephrology training is complete, but there was no ethics study	During the training “in residency the workload, it is small, it is more practical, right? then there was nothing in this sense” (I50); “you had the rotation period and then it’s no more... And you should do it, right?” (I32); “because this course there is already a complete course, so ethics and bioethics specifically, no” (I25).
	They are interested in studying ethics in Nephrology	The interest in studying ethics content in Nephrology was reported by almost half of the participants, and 10 (15.9%) are interested, but do not report a specific topic; 2 (3.2%) think about several topics; 34 (4.7%) had never thought about the subject; 17 (26.9%) are not interested or do not think about anything specific. 5 (7.9%) mentioned specific topics, according to the topics presented below.
	What they would like to study about ethics and nephrology	When asked about the topics that professionals would like to learn: expanded criteria in kidney transplantation, end-of-life care for kidney patients, confidentiality, social media, palliative nephrology, approach to patients who refuse dialysis, professional attitude, embracement, when to interrupt dialysis in the elderly or cancer patient, indication of dialysis in elderly people with degenerative diseases. However, some professionals did not know how to answer: “Only in nephro itself... I found bioethics very boring” (I13); “Hum... Nothing very specific to Nephrology that comes” (I41); “Specifically, nothing that comes to my mind right now” (I55).
	There should be a space in residency/training to discuss ethics	Suggestions from the interviewees: “That, I don’t know, but bioethical issues should be, we should have a space in the residency to discuss this, you know” (I32);So, yes. But I don’t know what exactly” (I61);is managing to specialize in specific things, of each of these, of these service areas, because it is very diverse, right?” (I35)

• Source: The authors.

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.

ACKNOWLEDGEMENTS

Our sincere thanks to the services and professionals who agreed to participate in this study and contribute to the growth of knowledge in the area of Nephrology.

REFERÊNCIAS

• ¹
  Beauchamp TL, Childress JF. Principles of biomedical ethics. 7th ed. New York: Oxford University Press; 2013.
• ²
  Rego S, Palácios M, Siqueira-Batista R. Bioética para profissionais da saúde. Rio de Janeiro: Fiocruz; 2020.
• ³
  Holmes D, Perron AM, Savoie M. Governing therapy choices: power/knowledge in the treatment of progressive renal failure. Philos Ethics Humanit Med. 2006;1(12):1-6.
• ⁴
  Friberg IO, Mårtensson L, Haraldsson B, Krantz G, Määttä S, Järbrink K. Patients’ perceptions and factors affecting dialysis modality decisions. Perit Dial Int. 2018; 38(5):334-42.
• ⁵
  Schell JO, Cohen RA. A communication framework for dialysis decision-making for frail elderly patients. Clin J Am Soc Nephrol. 2014;9(11):2014-21.
• ⁶
  Siqueira-Batista R, Gomes AP, Albuquerque VS, Cavalcanti FOL, Cotta RMM. Educação e competências para o SUS: é possível pensar alternativas à(s) lógica(s) do capitalismo tardio? Cienc Saude Colet . 2013;18(1):159-70. doi: https://doi.org/10.1590/S1413-81232013000100017.
  » https://doi.org/https://doi.org/10.1590/S1413-81232013000100017
• ⁷
  Ferrari AG, Silva CM da, Siqueira JE de. Ensino de bioética nas escolas de medicina da América Latina. Rev Bioét. 2018;26(2):228-34. doi: https://doi.org/10.1590/1983-80422018262243.
  » https://doi.org/https://doi.org/10.1590/1983-80422018262243
• ⁸
  Obregón JMV, Anjos MF. O nefrologista entre o poder e a vulnerabilidade em tempos tecnológicos. J Bras Nefrol. 2018;40(4):403-9.
• ⁹
  Brasil. Parecer CNE/CES nº 1.133/2001 - Diretrizes Curriculares Nacionais dos Cursos de Graduação em Enfermagem, Medicina e Nutrição. Brasilia: Ministério da Educação; 2001 [acesso em 18 jul 2021]. Disponível em: Disponível em: http://portal.mec.gov.br/dmdocuments/ces1133.pdf
  » http://portal.mec.gov.br/dmdocuments/ces1133.pdf
• ¹⁰
  Brasil. Resolução nº 15, de 13 de março de 2002. Estabelece as Diretrizes Curriculares para os cursos de Serviço Social. Brasilia: Ministério da Educação ; 2002.
• ¹¹
  Brasil. Resolução nº 3, de 20 de junho de 2014. Institui Diretrizes Curriculares Nacionais do Curso de Graduação em Medicina e dá outras providências. Brasilia: Ministério da Educação ; 2014.
• ¹²
  Brasil. Parecer nº 1071/2019, aprovado em 4 de dezembro de 2019. Revisão das Diretrizes Curriculares Nacionais (DCNs) dos Cursos de Graduação em Psicologia e estabelecimento de normas para o Projeto Pedagógico Complementar (PPC) para a Formação de Professores de Psicologia. Brasilia, DF: Ministério da Educação; 2019.
• ¹³
  Brasil. Resolução CNRM nº 32, de 8 de julho de 2021: Aprova a matriz de competências dos programas de Residência Médica em Nefrologia. Brasília: Ministério da Educação; 2021 [acesso em 18 jun 2022]. Disponível em: Disponível em: http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=195801-resolucao-cnrm-n-32-de-8-de-julho-de-2021-resolucao-cnrm-n-32-de-8-de-julho-de-2021-dou-imprensa-nacional&category_slug=2020&Itemid=30192
  » http://portal.mec.gov.br/index.php?option=com_docman&view=download&alias=195801-resolucao-cnrm-n-32-de-8-de-julho-de-2021-resolucao-cnrm-n-32-de-8-de-julho-de-2021-dou-imprensa-nacional&category_slug=2020&Itemid=30192
• ¹⁴
  D’Avila RL. Producing a moral code for medicine: advances and challenges in medical training. Rev Bras Saude Mater Infant. 2010;10(2):s399-408. doi: https://doi.org/10.1590/S1519-38292010000600019.
  » https://doi.org/https://doi.org/10.1590/S1519-38292010000600019
• ¹⁵
  Moura ACA, Mariano LÁ, Gottems LBD, Bolognani CV, Fernandes SES, Bittencourt RJ. Estratégias de ensino-aprendizagem para formação humanista, crítica, reflexiva e ética na graduação médica: revisão sistemática. Rev Bras Educ Med. 2020;44(3):e076-86. doi: https://doi.org/10.1590/1981-5271v44.3-20190189.
  » https://doi.org/https://doi.org/10.1590/1981-5271v44.3-20190189
• ¹⁶
  Brasil. Portaria nº 1.675, de 7 de junho de 2018. Altera a Portaria de Consolidação nº 3/GM/MS, de 28 de setembro de 2017, e a Portaria de Consolidação nº 6/GM/MS, de 28 de setembro de 2017, para dispor sobre os critérios para a organização, funcionamento e financiamento do cuidado da pessoa com Doença Renal Crônica - DRC no âmbito do Sistema Único de Saúde - SUS. Brasília: Ministério da Saúde; 2018 [acesso em 14 jul 2021]. Disponível em: Disponível em: https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/21054948/do1-2018-06-08-portaria-n-1-675-de-7-de-junho-de-2018-21054736
  » https://www.in.gov.br/materia/-/asset_publisher/Kujrw0TZC2Mb/content/id/21054948/do1-2018-06-08-portaria-n-1-675-de-7-de-junho-de-2018-21054736
• ¹⁷
  Bardin L. Análise de conteúdo. Ed. rev. e amp. São Paulo: Edições 70 Brasil; 2016.
• ¹⁸
  Brasil. Resolução nº 466, de 12 de dezembro de 2012: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Brasília: Ministério da Saúde , Conselho Nacional de Saúde, Comissão Nacional de Ética em Pesquisa; 2012 [acesso em 14 jul 2023]. Disponível em: Disponível em: http://bit.ly/1mTMIS3
  » http://bit.ly/1mTMIS3
• ¹⁹
  Nora CRD, Maffacciolli R, Vieira LB, Beghetto MG, Leites C, Ness MI. Ética e segurança do paciente na formação em enfermagem. Rev Bioét . 2022;30(3):619-27. doi: https://doi.org/10.1590/1983-80422022303555PT.
  » https://doi.org/https://doi.org/10.1590/1983-80422022303555PT
• ²⁰
  Gomes AP, Rego S. Pierre Bourdieu and medical education. Rev Bras Educ Med . 2013. 37;2:260-5.
• ²¹
  Oliveira EL de, Dantas AG de A, Britto Filho CO, Jacob MCM. Falhas de comunicação e epistemológicas limitam a abordagem da bioética na formação e na prática em saúde. Interface (Botucatu). 2021;25:e200679. doi: https://doi.org/10.1590/interface.200679.
  » https://doi.org/https://doi.org/10.1590/interface.200679
• ²²
  Marques LMNS da R, Fonseca SC, Milioni VC, Corbiceiro WCH. Quais são os valores morais essenciais para a formação médica? Rev Bioét . 2020;28(4):693-703. doi: https://doi.org/10.1590/1983-80422020284433.
  » https://doi.org/https://doi.org/10.1590/1983-80422020284433
• ²³
  Oliveira AF de, Oliveira EF de. Ética médica e bioética entre estudantes de medicina. Rev Bioét . 2022;30(3):628-35. doi: https://doi.org/10.1590/1983-80422022303556PT.
  » https://doi.org/https://doi.org/10.1590/1983-80422022303556PT
• ²⁴
  Biondo CS, Rosa RS, Ferraz MOA, Yarid SD. Perspectivas do conhecimento da bioética pelos acadêmicos de saúde para atuação profissional. Enferm Actual Costa Rica. 2018;35:63-74 [acesso em 18 jun 2022]. Disponível em: Disponível em: http://www.scielo.sa.cr/scielo.php?script=sci_arttext&pid=S1409-45682018000200063&lng=en http://dx.doi.org/10.15517/revenf.v0i35.30014.
  » https://doi.org/http://dx.doi.org/10.15517/revenf.v0i35.30014» http://www.scielo.sa.cr/scielo.php?script=sci_arttext&pid=S1409-45682018000200063&lng=en
• ²⁵
  Oliveira NB, Silva FVC, Assad LG. Competências do enfermeiro especialista em nefrologia. Rev Enferm UERJ. 2015;23(3):375-80 [acesso em 18 fev 2023]. Disponível em: Disponível em: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/viewFile/9789/13777
  » https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/viewFile/9789/13777
• ²⁶
  Martins V, Santos C, Duarte I. Educar para a bioética: desafio em enfermagem. Rev Bioét . 2022;30(3):498-504 [acesso em 16 fev 2023]. Disponível em: Disponível em: https://www.scielo.br/j/bioet/a/rqVCMhjwsptWPV3wXxrsqPH/?format=pdf⟨=pt
  » https://www.scielo.br/j/bioet/a/rqVCMhjwsptWPV3wXxrsqPH/?format=pdf⟨=pt
• ²⁷
  Silva ALNV, Candido MCFS, Duarte SJH, Sampaio ATL, Santos RM. Relação entre tempo de exercício profissional e ocorrências éticas em enfermagem. Rev Enferm UERJ . 2018;26:1-5 [acesso em 16 fev 2023]. Disponível em: Disponível em: https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/23058/26826
  » https://www.e-publicacoes.uerj.br/index.php/enfermagemuerj/article/view/23058/26826
• ²⁸
  Moura ACA de, Mariano L de Á, Gottems LBD, Bolognani CV, Fernandes SES, Bittencourt RJ. Estratégias de ensino-aprendizagem para formação humanista, crítica, reflexiva e ética na graduação médica: revisão sistemática. Rev Bras Educ Med . 2020;44(3): 1-11 [acesso em 16 fev 2023]. Disponível em: Disponível em: https://www.scielo.br/j/rbem/a/rFwC8ScKrLvKzZQLfs7gznF/?lang=pt#
  » https://www.scielo.br/j/rbem/a/rFwC8ScKrLvKzZQLfs7gznF/?lang=pt#
• ²⁹
  Diniz DF, Sousa FF, Hannes IE, Pereira RS, Ferraz FH. Bioética e diálise: uma revisão integrativa. Rev Bioét . 2019;14(sup):97-8. doi: https://doi.org/10.26512/rbb.v14iedsup.26275.
  » https://doi.org/https://doi.org/10.26512/rbb.v14iedsup.26275

• 6
  Evaluated by double blind review.

• SOURCES OF FUNDING

  The authors declare no sources of funding.

Chief Editor: Rosiane Viana Zuza Diniz. Associate Editor: Fernando Almeida.

Publication Dates

• Publication in this collection
  13 Sept 2024
• Date of issue
  2024

History

• Received
  05 Oct 2023
• Accepted
  15 July 2024