How Philosophy and Ethics Shape Nursing at Ribeirão Preto
In the heart of Brazil, a school of nursing is proving that the most critical tool in healthcare isn't a stethoscope, but a well-developed moral compass.
Imagine a nurse standing at the crossroads of a profound dilemma. A patient's life hangs in the balance, yet their deeply held religious beliefs forbid the very treatment that could save them. The medical solution seems clear, but the human solution requires something more—a sophisticated understanding of ethics that transcends textbook medicine.
This is the complex reality of modern nursing, where technical skill must be guided by ethical wisdom. At the University of São Paulo's Ribeirão Preto School of Nursing (EERP-USP), this understanding is woven into the very fabric of nursing education. Here, philosophy and bioethics are not abstract academic concepts but essential tools that prepare nurses to navigate the most challenging human situations with both expertise and compassion.
Before examining how EERP-USP integrates ethics into its curriculum, it's crucial to understand the principles that guide this approach. In healthcare, the dominant framework for ethical decision-making is principlism, popularized by Tom Beauchamp and James Childress in their seminal work, Principles of Biomedical Ethics 5 .
These four principles provide a shared moral language for healthcare professionals in our diverse, multicultural society:
Acknowledging a person's right to hold views, make choices, and take actions based on personal values and beliefs. This principle is the foundation for informed consent, requiring that patients fully understand their treatment options and are free to choose without coercion 5 .
The duty to "do no harm." This obliges healthcare professionals to avoid causing harm or injury to patients, whether through acts of commission or omission. It affirms the need for medical competence and a fundamental commitment to protect patients from harm 5 .
The obligation to act for the benefit of others, often summarized as "doing good." In medicine, this means developing a care plan designed to provide the most benefit to the patient in terms of other competing alternatives 5 .
The principle of fairness, requiring that people in similar circumstances be treated similarly. This is particularly important when dealing with scarce resources, ensuring they are distributed fairly 5 .
These principles are not hierarchical; no single principle automatically "trumps" another. Instead, nurses must learn to weigh and balance them against each other in the unique context of each patient's situation 5 . At EERP-USP, this balancing act is a core component of nursing education.
The commitment to ethical and rigorous nursing education at EERP-USP extends beyond its own classrooms. The school is a key participant in the São Paulo Nursing Courses Consortium for the Progress Test, a collaborative effort among eight public educational institutions in the state of São Paulo 2 .
Established in 2019, this consortium represents a groundbreaking initiative to collectively assess the knowledge and progress of nursing students across multiple universities. The Progress Test (PT) is a systematic and longitudinal assessment of student performance, used as a tool for the cognitive assessment of students' knowledge acquisition in a continuous and progressive manner 2 .
The test results enable analysis of the teaching-learning process, serving as a feedback tool for students and an academic management instrument, providing diagnostics and indications for changes in subjects or the curriculum 2 . For ethics education, the consortium's very structure embodies the principle of justice—ensuring that students across different institutions receive a comparably high standard of education and assessment.
| Institution | Abbreviation |
|---|---|
| School of Nursing of the University of São Paulo | EEUSP |
| Ribeirão Preto School of Nursing | EERP-USP |
| Universidade Federal de São Paulo Escola Paulista de Enfermagem | EPE-UNIFESP |
| Faculdade de Medicina de Marília | FAMEMA |
| Faculdade de Medicina de São José do Rio Preto | FAMERP |
| Universidade Estadual Paulista Faculdade de Medicina de Botucatu | UNESP |
| UNICAMP School of Nursing | UNICAMP |
| Universidade Federal de São Carlos | UFSCar |
Source: Adapted from the São Paulo Nursing Courses Consortium description 2
The consortium's work is structured into a meticulous process that includes planning, theme review, professor training, question elaboration, student registration, test application, and analysis of results 2 . This collaborative model allows for a broader analysis and benchmarking, strengthening nursing education by identifying training gaps and proposing alternatives for academic management across the state.
The tests prepared by the consortium are comprehensive evaluations structured around the core areas of knowledge mandated by Brazil's National Curriculum Guidelines for undergraduate nursing courses. The test consists of 120 objective questions distributed across six critical areas of knowledge 2 :
| Area of Knowledge | Number of Questions | Percentage of Test |
|---|---|---|
| Adult and Elderly Health | 35 | 29.2% |
| Child and Adolescent Health | 20 | 16.7% |
| Women's Health | 20 | 16.7% |
| Collective Health | 20 | 16.7% |
| Management | 15 | 12.5% |
| Mental Health | 10 | 8.3% |
| Total | 120 | 100% |
Source: Adapted from the methodology of the São Paulo Nursing Courses Consortium 2
Within these areas, many questions are designed to probe not just clinical knowledge but also ethical reasoning. For instance, a question might present a scenario involving a patient refusing treatment, requiring the student to apply the principles of autonomy, beneficence, and nonmaleficence to determine the most ethically sound response.
The psychometric analysis of the test questions categorizes them by difficulty (from "very easy" to "very difficult") and quality of discrimination between high-performing and low-performing students. In 2022, an impressive 82.5% of questions were considered to have adequate discrimination, indicating the test's refinement in assessing true competency 2 .
The work at EERP-USP goes beyond consortium testing. The school is a hub for innovative educational research, often employing rigorous experimental designs to validate teaching methods for complex skills, including ethical decision-making in clinical practice.
A recent quasi-experimental study conducted at the school exemplifies this research-to-practice approach. The study aimed to analyze the effect of an educational intervention on nursing students' knowledge of COVID-19, standard precautions (SP), and their compliance with infection control protocols 4 .
The study employed a clear, structured methodology 4 :
80 participating students first completed a questionnaire to assess their baseline knowledge of COVID-19 and standard precautions, and their self-reported compliance was measured using the Compliance with Standard Precautions Scale (CSPS).
The group received a combined teaching intervention, which included:
Immediately after the intervention, students completed the same knowledge questionnaire and compliance scale to measure any changes.
The results demonstrated a significant positive impact. After the educational intervention, an increase in correct answers was observed in 14 out of the 21 knowledge questions related to COVID-19 and SP measures, with seven showing statistically significant differences 4 .
In terms of practical compliance, significant improvements were observed in key behaviors such as using alcohol-based products for hand hygiene, proper disposal of sharps and PPE, and wearing appropriate protective gear when exposed to bodily fluids 4 .
| Aspect of Standard Precautions Compliance | Result |
|---|---|
| Use of alcohol-based products for hand hygiene | Significant improvement |
| Proper disposal of sharps containers | Significant improvement |
| Discarding PPE in designated locations | Significant improvement |
| Protecting wounds/injuries with waterproof dressings | Significant improvement |
| Wearing gowns/aprons when exposed to fluids | Significant improvement |
| Disposal of contaminated materials | Significant improvement |
Findings from the quasi-experimental study at EERP-USP 4
This study is a prime example of how EERP-USP uses empirical research to validate teaching methods. The educational intervention, rooted in ethical principles of nonmaleficence (preventing harm to patients and oneself) and beneficence (promoting patient well-being), proved to be an effective strategy for enhancing both knowledge and practical compliance—a crucial outcome for patient safety in a pandemic and post-pandemic world.
The contribution of philosophy, ethics, and bioethics to the Ribeirão Preto School of Nursing is not a sidebar to its curriculum; it is the beating heart of its educational mission. Through the foundational framework of the four principles of bioethics, the collaborative benchmarking of the Progress Test consortium, and evidence-based educational research, EERP-USP ensures its graduates are more than skilled technicians.
They are thoughtful practitioners, prepared to navigate the murky waters where medical capability meets human dignity, religious belief, and personal choice. They are equipped with a moral compass that guides them to respect patient autonomy while striving to do good and avoid harm, all within the constraints of a complex healthcare system.
In an era of rapid technological advancement, including the integration of tools like point-of-care ultrasound into nursing practice , this ethical foundation becomes even more critical. It ensures that as the how of nursing evolves, the why remains steadfastly rooted in a commitment to compassionate, just, and ethically sound care. The legacy of EERP-USP is a testament to the idea that the most advanced medical technology is only as good as the ethical wisdom of the hands that wield it.