Morality and critical thinking: essential competences in nurses' training


Joana Angélica Andrade DiasI, Helena Maria Scherlowski Leal DavidII, Benedita Maria Rêgo Deusdará RodriguesIII, Patrícia Lima Pereira PeresIV, Sandra Teixeira de Araújo Pacheco V, Marcia Silva de OliveiraVI

I Nurse. Doctoral Student, Graduate Studies Program in Nursing, State University of Rio de Janeiro. Adjunct Professor. State University of Southwest Bahia. Brazil. E-mail: joanauesb@gmail.com
II Nurse. Doctor. Assistant Professor, State University of Rio de Janeiro. Brazil. E-mail: helenalealdavid@gmail.com
III Nurse and Bachelor in Philosophy. Doctor. Full Professor, State University of Rio de Janeiro. Brazil. E-mail: benedeusdara@gmail.com
IV Nurse. Doctor. Assistant Professor, State University of Rio de Janeiro. Brazil. E-mail: patricia.uerj@hotmail.com
V Nurse. Doctor. Assistant Professor, State University of Rio de Janeiro. Brazil. E-mail: stapacheco@yahoo.com.br
VI Nurse. Doctor. "Pedro Ernesto" University Hospital, State University of Rio de Janeiro. Brazil. E-mail: marcia178rj@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.26391




Objective: to reflect on morality and critical thinking as competences to be developed during nursing training. Content: four previously specified thematic categories were discussed: ethics and moral or morality; moral development from Kohlberg's perspective; an approximation to critical thinking; and morality and critical thinking – all competences to be developed during nurses' training. Conclusion: critical and ethical/moral thinking makes it possible to act competently. This reveals a need to rethink undergraduate nursing courses in order to implement active, innovative and creative methodologies and strategies, drawing on a commitment by academic staff not only to stimulate students to think critically and morally, but encourage them to feel that they are co-participants in the teaching and learning process.

Keywords: Nursing; moral development; competence-based education; thought.




In view of the several scientific, technological and social transformations that have been occurring in the globalized world, and affecting several areas and subareas of knowledge, such as health and nursing, the employment market has been requiring professionals with increasingly more values and capacity of thinking in a critical and moral manner, so that such professionals can perform not only with technical and scientific competence, but also with other competences that will allow them to act with prudence, responsibility and commitment.

In this perspective, two elements can be highlighted: the critical thinking, which is fundamental in decision-making and problem-solving processes1 and an essential ability in nursing practice, and the moral competence or morality, understood as a universal phenomenon that shows itself mainly through the use of moral language2, which is also essential to decision-making and problem-solution processes identified during the nursing practice 3.

Therefore, this essay aims at reflecting about morals and critical thinking as abilities to be developed during th,e nurse education, by using methodological teaching strategies that lead the students to thinking critically and morally, so they can act with prudence and competence.

For such purpose, this article is based on the critical reading of CNE/CES Resolution No. 3, of November 7, 2001, which establishes the National Curricular Guidelines (DCN) for Undergraduate Nursing Courses4, books that address ethic, morals, skills and critical thinking, and articles collected from the Virtual Health Library (BVS) to discuss the four preset subject categories.



Ethics and Morals or Morality

The word "ethics" comes from Greek ethos and meant "dwelling", a place where one lives. The word "morals" comes from Latin mos, moris, and meant "custom". Currently, they both have a similar meaning, that is, a way of being or a character resulting from practicing "certain customs or habits that are considered good"2:20.

In view of such etymological coincidence, many people use these words to refer to an attitude considered morally correct, which is perfectly possible, as long as they refer to them as a consolidated moral code. However, in the antiquity, Greek philosophers referred to ethics as a philosophy or moral discipline that allows for reflection on several existing morals and ways to rationally justify the moral life, indirectly guiding human behaviors, and this is the academic approach to understand it, even though some authors disagree with any distinction between them both3.

The idea of morals in particular is generally understood as a "set of principles, beliefs and rules"3:49, as well as values that orient the behavior, passed on from one generation to another, and recognized as good heritage that will allow people to live a happy and fair life. This leads to the idea that it is impossible to think about morals without considering human values such as freedom, equality, active respect, tolerance, solidarity, willingness to dialogue, among others (inevitable components of human society), making it impossible to imagine life without them, which are understood as integrators of all other values, such as esthetic, religious, intellectual, etc5.

Further, morals or morality (understood as a phenomena) can be characterized by the accomplishment of happiness as pleasure (Hedonism) or self-fulfillment (Eudaimonism); adjustment to human standards; willingness to solve conflicts in a pacific manner; appreciation of virtues that are specific to the community in which a certain individual is integrated, and solidarity among its members; and appreciation of universal principles that allows for a critical evaluation of moral notions of others and one's own community2.

Furthermore, it is understood that the human being is not born ethical, but he has a prio­ri the conditions required to develop more and more his ethical and moral thinking, a construction that occurs throughout his life6. Social relations are extremely important to such development, since, according to constructivism, the formation of moral consciousness occurs from the individual's interaction with the environment, and not because of environment influences 7.

Considering such ideas, we highlight that the socialization process experienced by the nurse begins in the moral development during the childhood and continues throughout their life, including during the higher education studies, covering matters and values related to the professional environment and special issues related to health education.

Moral development in Kohlberg's perspective

Unlike Freud, Skinner, and Piaget, Kohlberg researched moral development as his main object of study7 and, based on Piaget's ideas, he defended the thesis that morals is a conscious domain at psychological level, responsible for adjusting the individual's actions while interacting with other individuals when they judge what is right and what is wrong. Such judgements are based on the principle of justice built from the genesis of human beings and continuing throughout all their life, with the social context having a fundamental role in this process 3.

In an attempt to better explain how maturity or development of moral thinking occurs, such author developed an explanatory model that comprises three levels (pre-conventional, conventional, and post-conventional), each of them with two development stages. The pre-conventional stage is individual and self-interest driven and comprises stages I and II. In stage I, individuals guide themselves by obedience in order to avoid punishment, with total predominance of heteronomous morality, and, in stage II, they present an egocentric-driven behavior, aiming at satisfying their own desires, and occasionally of others, provided that they first receive something in return, with predominance of individual morality. Most children younger than 9 years of age are in this stage9,10.

The conventional level is characterized for the perspective that the people can already recognize themselves as members of society, comprising stages III and IV. In stage II, they guide themselves by the conservation of values that prevail in the community and their circle of friends and end up acting driven by the desire of being accepted and approved by others. The basic rule is to act towards others as you would like them to act towards you. In stage IV, they guide themselves by the law and preservation of social order and the values prevailing in society, evidencing the willingness to follow the rules as established, for the feeling of the duty accomplished. 9,10

The post-conventional level is characterized by the recognition of universal moral principles from the social commitments and comprises stages V and VI. In stage V, people guide themselves by the social contract in deference both to civil and individual rights and fair is evaluated according to personal values and opinions. The applicability of laws and rules may start to be questioned with possibility of changes due to reasons of social utility. In the sixth and last stage, people guide themselves by the universal ethic principles (justice, reciprocity, equality, respect and dignity) from which social commitments derive, considering that people are themselves a purpose and must be acknowledged as such. Based on that understanding, social rules are not always recognized as the best and, therefore, are rebuilt 9,10.

It can be highlighted that the sequence of those stages is invariable and independent from culture, that is, any person will follow the same order in the course of his/her moral development and there is no possibility of advancing to a higher level without passing through the subsequent level first. Besides, the advance from a stage to another occurs whenever the individual experiences a conflict situation and amid several points of view, manages to coordinate those different perspectives and find a solution to the problem, restructuring the perspectives at issue 10.

However, it must be highlighted that the fact of reaching high levels of logical thinking and social consciousness does not mean that a person will be able to achieve a high level of ethical thinking or morality. This is because, although he/she may have all logical structures required for a high moral thinking and is able to coordinate different perspectives in a conflict situation, he/she may not present the same complexity as regards the moral judgment, as it is in the quality of such set of skills that the ethical nature of an individual is established 3, which needs to be well developed, so he/she may also become a critical thinker.

An approach to critical thinking

Object of study of several subjects comprising human and health science fields such as teaching, philosophy, psychology, nursing, medicine, among others, critical thinking can be described as "a fundamental skill for all areas in which the human being may act" and so that success can be achieved whether in personal or professional life 1:122.

Critical thinking is a complex process 11, comprised not only by cognitive abilities, but also by mental habits and behavioral abilities, which are construed as attitudes taken by a critical thinker through a conscious, social and humanistic effort and the involvement with a situation requiring a decision to be made 12. Reflect critically on a situation allows contradictions inherent to this phenomena to be understood, as well as thinking on interventions that could be possibly made 13.

In this perspective, a professional is required to have a critical thinker's characteristics and attitudes, which are mostly built during a professional's training 1,14,.e.g., responsibility, honesty, curiosity, autonomy, confidence, discernment, tolerance, justice, practicality, respect for diversity, courage, patience, persistence, flexibility, empathy, reflexivity, among others.

This way of thinking allows the enhancement of a nurse's clinical reasoning and, consequently, a qualified and safe care 12, requiring the acquisition of interpersonal, technical and intellectual skills and abilities, as well as knowledge of biological and social sciences, theories, and nursing care process, among others 15.

Therefore, critical thinking corresponds to an active, cognitive and deliberate process that requires the use of one's mind to reflect, make inferences, conclusions and decisions 16 and it lies in policies, laws, rules, science, scientific method, logic, intuition, creativity and ethical and moral principles 14,15. Thus, critical thinking is also understood as a skill to be developed during a professional's training.

Morality and critical thinking: skills to be developed during a nurse's training

For this study, the reflection on subject category of morality and critical thinking during a nurse's training is based on CNE/CES Resolution No. 3, of November 7, 2001, which approved the DCN for the Undergraduate Nursing Course. The DCN do not expressly hold critical thinking and ethical/moral thinking as skills or abilities to be acquired by an undergraduate student during education. However, when describing skills or abilities to be acquired, in articles four and five, the DCN refer to critical thinking and ethical/moral thinking by using expressions asable to think critically, ethical/bioethical principles and undertake an ethical commitment, showing the importance of those cognitive processes to be developed during nurse education 4:1-3.

According to the professional profile described in article three of the DCN, a nurse's training, besides being generalist and humanistic, must be critical and reflexive, and guided by ethical/moral principles 4 , which reaffirms the importance of these processes to be developed during education, and proves those skills to be necessary for nursing practice.

Accordingly, every educational institution that aims at complying with the provisions of article 14 of such resolution, is considered to be in the path of training nurses who hold those two skills, especially by focusing on the guarantee of a "critical, reflexive and creative teaching" (Item I) and education oriented towards "citizenship and full engagement in society" (Item III); by implementing methodological teaching strategies that stimulate students "to reflect on social reality" and to articulate "knowledge, know-how and coexistence" (Items V and VI); by stimulating "collective discussions and interpersonal relationships" (Item VII); and by fostering an education that values "ethical and humanistic aspects", which contribute to the development of "attitudes and values oriented towards citizenship and solidarity" (Item VIII) 4:5-6.

Active methods of teaching and/or innovative and creative pedagogical strategies are pointed out as ways to help nurses to develop critical thinking skills 17. The most frequently mentioned methods and strategies in an essay were problem-based learning and case study or problem situation 18. However, there are other studies mentioning collaborative and/or tutorial learning 19, simulated practices, group discussions 20, nursing process 21, and clinical cases 16.

Some of those methods and strategies can also be applied to teaching and learning of moral development, provided that they bring about analysis of ethical conflicts. However, in many studies the most frequently mentioned technique is the moral dilemma discussion technique 3,6,22-25, which allows students to think morally, by themselves, and make decisions autonomously, developing the so-called open moral 5.

Finally, because critical thinking and ethical/moral thinking are skills to be developed throughout the professional education, they need to be valued in the moment of (re)building curriculums for Undergraduate Nursing Courses. Such courses could be provided through specific subjects, as well as transversal contents discussed in other subjects, through the commitment previously undertaken by all teaching staff of the course8,18-20,26.



Firstly, the study allowed a reflection on concepts of ethics, morals or morality and on how morality is developed according to Kohlberg, a scholar who built a theoretical model in order to evidence that it happens in a logical sequence comprised by three levels and six stages. Secondly, the study allowed an approach to the concept of critical thinking and the possibility of rethinking the importance of those two skills being acquired during nurse education.

In addition, the interconnection between the skills could be noted, since it is not possible to imagine a professional that can think in a critical and reflexive way without developing ethical and moral skills or how a professional could have ethical and moral competence without having developed the capacity of thinking in a critical and reflexive way, because conflictual moments, whether of ethical/moral nature or not, will always require criticism and reflection before an action is taken.

In this sense, the objective previously intended for this study was believed to be achieved because it allowed the reader to understand critical thinking and moral thinking or morality as skills to be developed by nursing students, so that when becoming the professionals they intended to be, they be able to act in a competent way, not only in relation to technical, scientific and political performance but also in relation to ethical/moral and critical performance.

For this purpose, educational institutions need to rethink their curriculums and implement active, innovative and creative strategies and methods of teaching through a commitment undertaken by all teaching staff, in all subjects of the course, so that students are fostered to think critically and morally, as well as encourage students to feel as co-participants of the teaching and learning process.



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